Multiple Choice
1. A nurse is assessing a client who is experiencing occasional feelings of sadness because of the
recent death of a beloved pet. The clients appetite, sleep patterns, and daily routine have not
changed. How should the nurse interpret the clients behaviors?
1. The clients behaviors demonstrate mental illness in the form of depression.
2. The clients behaviors are extensive, which indicates the presence of mental illness.
3. The clients behaviors are not congruent with cultural norms.
4. The clients behaviors demonstrate no functional impairment, indicating no mental illness.
ANSWER: 4
Rationale: The nurse should assess that the clients daily functioning is not impaired. The client who
experiences feelings of sadness after the loss of a pet is responding within normal expectations.
Without significant impairment, the clients distress does not indicate a mental illness.
Cognitive Level: Analysis Integrated
Process: Assessment
2. At what point should the nurse determine that a client is at risk for developing a mental
illness?
1. When thoughts, feelings, and behaviors are not reflective of the DSM-5 criteria.
2. When maladaptive responses to stress are coupled with interference in daily functioning.
3. When a client communicates significant distress.
4. When a client uses defense mechanisms as ego protection.
ANSWER: 2