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A healthcare professional is assessing a client who appears to be experiencing moderate anxiety during questioning. Which symptom shouldn't the healthcare professional expect?
- A. Fidgeting
- B. Laughing inappropriately
- C. Palpitations
- D. Nail biting
Correct Answer: C
Rationale: Palpitations are not typically associated with moderate anxiety. Fidgeting, laughing inappropriately, and nail biting are common behavioral symptoms of heightened stress levels. Palpitations may be more indicative of physiological responses, such as increased heart rate, which can occur in severe anxiety or panic attacks. Other signs of severe anxiety include restlessness, difficulty concentrating, muscle tension, and sleep disturbances.
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A healthcare professional is assessing a client with major depressive disorder. Which of the following findings should the professional expect? Select one that does not apply.
- A. Anhedonia
- B. Hypersomnia
- C. Fatigue
- D. Flight of ideas
Correct Answer: D
Rationale: In major depressive disorder, common findings include anhedonia (loss of interest or pleasure), hypersomnia (excessive sleepiness), fatigue, and feelings of worthlessness. Flight of ideas, characterized by racing thoughts and rapid speech, is more commonly associated with bipolar disorder, particularly during manic episodes. Therefore, 'Flight of ideas' does not apply to the expected findings in major depressive disorder.
Which of the following symptoms should a healthcare professional expect to assess in a client diagnosed with major depressive disorder? Select one that does not apply.
- A. Loss of interest or pleasure
- B. Decreased ability to concentrate
- C. Significant weight loss or gain
- D. Increased energy
Correct Answer: D
Rationale: Symptoms of major depressive disorder include a loss of interest or pleasure, decreased ability to concentrate, significant weight loss or gain, and feelings of worthlessness or excessive guilt. Increased energy is not typically associated with major depressive disorder; instead, fatigue is more common. Clients with major depressive disorder often experience a lack of energy, motivation, or enthusiasm, leading to feelings of lethargy and fatigue. Therefore, increased energy is an atypical symptom in major depressive disorder, making it the correct answer.
A teenage boy is attracted to a female teacher. Without objective evidence, a school nurse overhears the boy state, 'I know she wants me.' This statement reflects which defense mechanism?
- A. Displacement
- B. Projection
- C. Rationalization
- D. Sublimation
Correct Answer: B
Rationale: The correct answer is B: Projection. The nurse should determine that the client's statement reflects the defense mechanism of projection. Projection involves attributing one's unacceptable feelings or impulses to another person. By projecting these feelings onto someone else, the individual reduces their own anxiety. Displacement involves transferring feelings from one target to another, not attributing them to another person. Rationalization involves making excuses to justify behavior, not attributing feelings to others. Sublimation involves channeling unacceptable drives or impulses into more constructive and acceptable activities, not attributing feelings to another person.
Which is a correct evaluation of the new psychiatric nurse's statement regarding a client's use of defense mechanisms?
- A. Defense mechanisms can be self-protective responses to stress and need not be eliminated.
- B. Defense mechanisms are a maladaptive attempt by the ego to manage anxiety and should always be eliminated.
- C. Defense mechanisms, used by individuals with weak ego integrity, should be discouraged but not eliminated.
- D. Defense mechanisms cause disintegration of the ego and should be fostered and encouraged.
Correct Answer: A
Rationale: The correct evaluation is that defense mechanisms can be self-protective responses to stress and do not necessarily need to be eliminated. These mechanisms serve the purpose of reducing anxiety during times of stress. While some defense mechanisms may be maladaptive, they can also help individuals cope with challenging situations. It is essential for the nurse to recognize that addressing defense mechanisms should be done sensitively, as they may be crucial for the client's emotional regulation. Encouraging the development of healthy coping skills while acknowledging the role of defense mechanisms in managing stress is a balanced approach in psychiatric care. Choice B is incorrect because completely eliminating defense mechanisms is not always feasible or beneficial. Choice C is incorrect as it oversimplifies the relationship between defense mechanisms and ego integrity. Choice D is incorrect as it misrepresents the role of defense mechanisms in ego functions.
A physically and emotionally healthy client has just been fired. During a routine office visit, he states to a nurse: 'Perhaps this was the best thing to happen. Maybe I'll look into pursuing an art degree.' How should the nurse characterize the client's appraisal of the job loss stressor?
- A. Irrelevant
- B. Harm/loss
- C. Threatening
- D. Challenging
Correct Answer: D
Rationale: The client's statement indicates that he views the job loss as an opportunity for growth and a new direction in life rather than a threat or harm/loss. He sees it as a challenge and is considering it positively, demonstrating resilience and adaptability in the face of adversity. Choice A, 'Irrelevant,' is incorrect as the client's response shows relevance and a positive outlook. Choice B, 'Harm/loss,' is incorrect as the client does not express a sense of harm or loss but rather opportunity. Choice C, 'Threatening,' is incorrect as the client's response does not convey fear or threat but rather a positive reframe of the situation.