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A child is brought to the emergency room with a broken arm. Because of other injuries, the nurse suspects the child may be a victim of abuse. When the nurse tries to give the child an injection, the child's mother becomes very loud and shouts, 'I won't leave my son! Don't you touch him! You'll hurt my child!' What is the best interpretation of the mother's statements? The mother is
- A. regressing to an earlier behavior pattern.
- B. sublimating her anger.
- C. projecting her feelings onto the nurse.
- D. suppressing her fear.
Correct Answer: C
Rationale: The correct answer is (C) projecting her feelings onto the nurse. The mother's behavior suggests that she is attributing her own actions or feelings to the nurse, which is a form of projection. Option (A) regressing to an earlier behavior pattern is not the best fit in this context. Option (B) sublimating her anger is not applicable based on the given scenario. Option (D) suppressing her fear cannot be inferred from the provided information.
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A 45-year-old female client is admitted to the psychiatric unit for evaluation. Her husband states that she has been reluctant to leave home for the last six months. The client has not gone to work for a month and has been terminated from her job. She has not left the house since that time. This client is displaying symptoms of which disorder?
- A. Claustrophobia.
- B. Acrophobia.
- C. Agoraphobia.
- D. Necrophobia.
Correct Answer: C
Rationale: The correct answer is C, Agoraphobia. Agoraphobia involves the fear of situations where escape might be difficult, often leading to the individual avoiding public spaces or leaving their home. In this case, the client's reluctance to leave home, not going to work, and staying indoors for an extended period align with the symptoms of agoraphobia. Choices A, B, and D are incorrect. Claustrophobia is the fear of confined spaces, acrophobia is the fear of heights, and necrophobia is the fear of death or dead things, none of which are consistent with the client's symptoms described in the scenario.
A client is scheduled to complete a positron emission tomography (PET) scan. The client asks the nurse to explain the reason the test was prescribed. How should the nurse respond?
- A. Images indicate the presence of tumors and scars.
- B. The scan clearly outlines structures of the brain.
- C. Results show activity in various portions of the brain.
- D. PET shows biochemical levels of neurotransmitters.
Correct Answer: C
Rationale: The correct answer is C. PET scans are primarily used to detect and observe the metabolic activity in various parts of the brain. This helps in diagnosing conditions related to brain function, such as tumors, brain disorders, and overall brain activity. Choices A, B, and D are incorrect because PET scans focus on metabolic activity and functions in the brain rather than solely indicating the presence of tumors, outlining brain structures, or showing biochemical levels of neurotransmitters.
A client who has been diagnosed with borderline personality disorder is exhibiting manipulative behavior. What is the most important intervention for the LPN/LVN to implement?
- A. Set clear, consistent limits on manipulative behavior.
- B. Ignore the manipulative behavior to avoid reinforcing it.
- C. Remind the client that manipulative behavior is unacceptable.
- D. Explain the consequences of manipulative behavior to the client.
Correct Answer: A
Rationale: Setting clear, consistent limits on manipulative behavior is the most important intervention for a client diagnosed with borderline personality disorder. This approach helps establish boundaries, maintain a therapeutic environment, and provide structure for the client. Choice B is incorrect because ignoring manipulative behavior can lead to its reinforcement. Choice C, while important, may not be as effective as directly setting limits. Choice D focuses on consequences rather than immediate intervention, making it less effective than setting clear limits.
A male client approaches the nurse with an angry expression on his face and raises his voice, saying, 'My roommate is the most selfish, self-centered, angry person I have ever met. If he loses his temper one more time with me, I am going to punch him out!' The nurse recognizes that the client is using which defense mechanism?
- A. Denial
- B. Projection
- C. Rationalization
- D. Splitting
Correct Answer: B
Rationale: The correct answer is B: Projection. In this scenario, the client is projecting his own feelings of anger and selfishness onto his roommate. Projection is a defense mechanism where individuals attribute their own unacceptable thoughts, feelings, and motives to another person. Choices A, C, and D are incorrect. Denial is refusing to acknowledge an aspect of reality or experience. Rationalization is providing logical-sounding reasons to justify unacceptable behaviors or feelings. Splitting is seeing individuals as all good or all bad, with no middle ground.
In observing a client who is pacing, agitated, and presenting aggressive gestures, with rapid speech pattern and belligerent affect, what is the immediate priority of care for the nurse?
- A. Provide safety for the client and other clients on the unit
- B. Provide the clients on the unit with a sense of comfort and safety
- C. Assist the staff in caring for the client in a controlled environment
- D. Offer the client a less stimulated area to calm down and gain control
Correct Answer: A
Rationale: In a situation where a client is displaying aggression and agitation, the immediate priority of care for the nurse is to ensure safety for the client and others on the unit. Providing a safe environment and implementing calming measures take precedence over other interventions. Option A is the correct choice as it addresses the crucial need for safety in a potentially volatile situation. Options B, C, and D, although important, do not address the primary concern of ensuring safety for all individuals involved.