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A client is under a great deal of stress. Which nursing recommendation would be least helpful in assisting the client in coping with stress? Select one that doesn't apply.
- A. Enjoy a pet.
- B. Spend time with a loved one.
- C. Listen to music.
- D. Focus on the stressors.
Correct Answer: D
Rationale: Focusing on the stressors can exacerbate stress levels in the client's life rather than helping to cope with it. Engaging in activities such as enjoying a pet, spending time with loved ones, and listening to music are known to be stress-relieving and can aid in coping with stress. It is essential to encourage strategies that promote relaxation and positive emotions, rather than fixating on the stressors that may worsen the client's condition. Therefore, 'Focus on the stressors' is the least helpful recommendation as it does not contribute to stress management.
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Which should the individual recognize as an example of the defense mechanism of repression?
- A. A student aware of the need to study for tomorrow's test goes to a movie instead.
- B. A woman whose son was killed in Iraq does not believe the military report.
- C. A man who is unhappily married goes to school to become a marriage counselor.
- D. A woman was raped when she was 12 and no longer remembers the incident.
Correct Answer: D
Rationale: Repression is a defense mechanism where distressing thoughts, feelings, or memories are pushed out of conscious awareness to protect the individual from emotional pain. In this scenario, the woman's inability to recall the traumatic event of being raped at the age of 12 indicates repression in action. Choices A, B, and C do not represent repression. Choice A reflects procrastination, choice B suggests denial, and choice C indicates sublimation as the man is channeling his unhappiness into a constructive pursuit.
During a mental status examination, which of the following components should be included in the assessment? Select one that doesn't apply.
- A. Appearance and behavior
- B. Thought processes
- C. Mood and affect
- D. The greater the cultural distance from the mainstream of society, the greater the likelihood that the illness will be treated with sensitivity and compassion.
Correct Answer: D
Rationale: During a mental status examination, key components to be assessed include the client's appearance and behavior, thought processes, mood and affect, and cognitive function. These components help in evaluating the client's mental health status. The statement about cultural distance and illness treatment is not a part of a mental status examination and is not relevant to the assessment of mental health. Choices A, B, and C are essential components of a mental status examination and contribute to a comprehensive evaluation of an individual's mental well-being.
A healthcare professional is conducting education on anxiety and stress management. Which of the following should be identified as the most important initial step in learning how to manage anxiety?
- A. Diagnostic blood tests
- B. Awareness of factors creating stress
- C. Relaxation exercises
- D. Identifying support systems
Correct Answer: B
Rationale: The correct answer is B: Awareness of factors creating stress. In managing anxiety, the first crucial step is recognizing and being aware of the factors that contribute to stress. Without this awareness, it becomes challenging to effectively address and manage anxiety. Diagnostic blood tests are not typically the initial step in managing anxiety; they may be used to rule out other medical conditions but are not the primary focus. While relaxation exercises can be helpful in managing anxiety, understanding the root causes of stress takes precedence. Identifying support systems is important but comes after recognizing the stress factors to develop a comprehensive management plan.
A client with obsessive-compulsive disorder (OCD) is being cared for by a nurse. Which intervention should the nurse include in the plan of care?
- A. Encourage the client to suppress compulsive behaviors.
- B. Set strict limits on the amount of time the client can engage in compulsive behaviors.
- C. Allow the client to perform compulsive behaviors as needed.
- D. Gradually limit the amount of time allotted for compulsive behaviors.
Correct Answer: D
Rationale: In caring for a client with OCD, it is essential to gradually limit the time allotted for compulsive behaviors. This intervention helps the client develop alternative coping mechanisms. Encouraging suppression or setting strict limits on compulsive behaviors can exacerbate the client's anxiety, making it crucial to approach the care plan with a gradual reduction strategy. Allowing the client to perform compulsive behaviors as needed does not promote progress towards managing OCD symptoms and may reinforce maladaptive patterns of behavior.
A client with bipolar disorder is experiencing a depressive episode. Which of the following interventions should the nurse not implement?
- A. Agree with the client's delusions to avoid confrontation.
- B. Monitor for signs of suicidal ideation
- C. Promote a regular sleep schedule
- D. Discourage the expression of negative feelings
Correct Answer: A
Rationale: During a depressive episode in bipolar disorder, it is crucial not to agree with the client's delusions to avoid reinforcing false beliefs. Monitoring for signs of suicidal ideation is essential for safety. Promoting a regular sleep schedule can help stabilize mood. Discouraging the expression of negative feelings is not recommended as it is important to allow clients to express their emotions and feel heard.