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A client diagnosed with OCD spends hours bathing and grooming. During a one-on-one interaction, the client discusses the rituals in detail but avoids any feelings that the rituals generate. Which defense mechanism should the nurse identify?
- A. Dissociation
- B. Rationalization
- C. Sublimation
- D. Intellectualization
Correct Answer: D
Rationale: Intellectualization is a defense mechanism where an individual focuses on rational, logical explanations to distance themselves from uncomfortable emotions. In this scenario, the client discusses the OCD rituals in a detailed and analytical manner, avoiding the emotional aspects associated with them. This behavior reflects intellectualization rather than dissociation, rationalization, or sublimation. Dissociation involves a disconnection from reality, rationalization is the attempt to justify behaviors, and sublimation is redirecting unacceptable impulses into socially acceptable activities.
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During the assessment of an adolescent who collapsed during Olympic figure skating training and was diagnosed with severe malnutrition due to anorexia nervosa, which client statement supports the use of a family-based approach?
- A. I eat just as much as everyone else on the team
- B. I'm tired of fighting with my parents about eating
- C. I just didn't drink enough water during practice
- D. I have to practice until my skating routine is perfect
Correct Answer: B
Rationale: The statement 'I'm tired of fighting with my parents about eating' indicates a struggle related to food and parental conflicts, suggesting family dynamics play a role in the client's eating disorder. In cases of anorexia nervosa in adolescents, involving the family in the treatment process through a family-based approach has shown to be effective. This approach recognizes the influence of family interactions on the development and maintenance of eating disorders, aiming to improve communication, support, and understanding within the family unit to facilitate recovery.
A 10-year-old boy breaks his mother's vase while playing. When the mother asks who broke the vase, the little boy says that his sister did it. The little boy is exhibiting which defense mechanism?
- A. Projection
- B. Displacement
- C. Dissociation
- D. Sublimation
Correct Answer: A
Rationale: Projection is a defense mechanism where one attributes their own unacceptable thoughts, feelings, or impulses onto another person. In this scenario, the little boy is projecting his actions onto his sister by falsely claiming she broke the vase. Displacement involves transferring emotions from the original source to a substitute target. Dissociation is a disconnection between thoughts, identity, consciousness, and memory. Sublimation is the redirection of unacceptable impulses into socially acceptable activities.
While auditing care plans for clients with eating disorders, the nurse realizes that a nursing diagnosis appropriate for a client with anorexia nervosa as well as for a client with bulimia nervosa is
- A. Risk for imbalanced body temperature
- B. Ineffective denial
- C. Chronic low self-esteem
- D. Adult failure to thrive
Correct Answer: C
Rationale: Chronic low self-esteem is a nursing diagnosis that can be applicable to clients with both anorexia nervosa and bulimia nervosa. These eating disorders are often associated with distorted body image, feelings of inadequacy, and low self-esteem. Clients with these conditions may engage in harmful behaviors related to their self-image, making chronic low self-esteem a relevant nursing diagnosis for them.
The client recently survived a plane crash and is assessed by the nurse. Which client statement would cause the nurse to suspect that the client may be experiencing PTSD?
- A. I believe that I was meant to survive this accident so that I can focus on the important things in life
- B. Although I have nightmares sometimes, I have started going to church to show gratitude for surviving the crash
- C. I am so afraid that I will never be able to fly again, but I know that it will take a while
- D. I keep having these thoughts about the crash that just pop into my mind at random times
Correct Answer: D
Rationale: Experiencing intrusive thoughts about a traumatic event, such as a plane crash, that occur unexpectedly and repeatedly is a common symptom of Post-Traumatic Stress Disorder (PTSD). These thoughts can be distressing and are often a key indicator of PTSD. Options A, B, and C demonstrate coping mechanisms and fears related to the traumatic event but do not specifically address the hallmark symptom of intrusive thoughts. Therefore, option D is the correct choice as it aligns with a potential symptom of PTSD.
After 1 week of continuous mental confusion, an elderly African American client is
admitted with a preliminary diagnosis of a neurocognitive disorder due to dementia.
Which statement would cause the nurse to question this diagnosis?
- A. There has been no triiodothyronine or thyroxine level evaluation ordered
- B. Neurocognitive disorders do not typically occur in African American clients
- C. The symptoms presented are more indicative of parkinsonism
- D. Dementia does not develop suddenly
Correct Answer: D
Rationale: