Nokea
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.
You may also like to solve these questions
What assessment is the priority focus for a client with major depression?
- A. Mood and affect.
- B. Suicidal ideation.
- C. Nutritional status.
- D. Fluid and electrolyte balance.
Correct Answer: B
Rationale: The correct answer is B: Suicidal ideation. When dealing with a client diagnosed with major depression, assessing for suicidal ideation is of utmost importance. Individuals with major depression have an increased risk of suicide; hence, evaluating their risk for self-harm is crucial. Mood and affect, while important, come secondary to ensuring the safety of the client. Nutritional status and fluid and electrolyte balance are essential components of care but are not the priority when dealing with a client with major depression.
The LPN/LVN should include which interventions in the plan of care for a severely depressed client with neurovegetative symptoms? (select one that does not apply.)
- A. Permit rest periods as needed.
- B. Speaking slowly and simply.
- C. Place the client on suicide precautions.
- D. Limit and discourage food and fluid intake.
Correct Answer: D
Rationale: For a severely depressed client with neurovegetative symptoms, the care plan should include rest, simple communication, suicide precautions, monitoring intake, and encouraging mild exercise. Limiting and discouraging food and fluid intake is not appropriate as proper nutrition and hydration are essential for overall well-being. This choice could lead to further complications and is not recommended in the care of a depressed client.
A client with major depressive disorder is prescribed a selective serotonin reuptake inhibitor (SSRI). Which side effect should the nurse educate the client about?
- A. Hypertension.
- B. Sexual dysfunction.
- C. Increased appetite.
- D. Weight gain.
Correct Answer: B
Rationale: The correct answer is B: Sexual dysfunction. Sexual dysfunction is a common side effect of SSRIs. While hypertension (A) can occur with other medications, it is not typically associated with SSRIs. Increased appetite (C) and weight gain (D) are potential side effects of some antidepressants, but sexual dysfunction is more specific to SSRIs. Therefore, the nurse should educate the client about the risk of sexual dysfunction when taking an SSRI.
A nurse is providing discharge teaching to a client with major depressive disorder who is prescribed fluoxetine (Prozac). What is the most important teaching point for the nurse to include?
- A. You may experience dizziness, so avoid driving.
- B. It may take several weeks to feel the full effect of the medication.
- C. Avoid foods high in tyramine while taking this medication.
- D. Take this medication only when you feel depressed.
Correct Answer: B
Rationale: The correct answer is B because SSRIs like fluoxetine typically take several weeks to reach their full therapeutic effect, so it's important to set realistic expectations for the client. Choice A is incorrect as dizziness is a common side effect but not the most important teaching point. Choice C is incorrect as avoiding tyramine-rich foods is more relevant for MAOIs. Choice D is incorrect as fluoxetine should be taken consistently, not only when the client feels depressed, to maintain therapeutic blood levels.
A client with schizophrenia is being treated with haloperidol (Haldol). The client reports feeling restless and unable to sit still. What should the nurse do first?
- A. Instruct the client to take deep breaths and relax.
- B. Assess the client for signs of akathisia.
- C. Encourage the client to engage in physical activity.
- D. Administer a PRN dose of lorazepam (Ativan).
Correct Answer: B
Rationale: Restlessness and inability to sit still are signs of akathisia, an extrapyramidal side effect of antipsychotic medications. The nurse should first assess the client for signs of akathisia by observing their movements and behavior. Assessing for akathisia is crucial to differentiate it from other conditions and to intervene appropriately. Instructing the client to relax or engage in physical activity may not address the underlying issue of akathisia. Administering lorazepam should not be the first action as it may mask the symptoms of akathisia temporarily without addressing the root cause.