A healthcare professional is assessing a client's use of defense mechanisms. Which statement would indicate to the healthcare professional that the client is using the defense mechanism of projection?
- A. The client accuses others of being angry when it is the client who is angry.
- B. The client refuses to acknowledge a problem despite evidence to the contrary.
- C. The client attributes his own feelings of hostility to others.
- D. The client avoids dealing with painful feelings by focusing on something else.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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When developing a care plan for a client with generalized anxiety disorder (GAD), which of the following interventions should not be included?
- A. Encourage the client to avoid anxiety-provoking situations.
- B. Teach the client relaxation techniques.
- C. Encourage the client to express their feelings.
- D. Provide a structured daily routine.
Correct Answer: A
Rationale: When caring for a client with generalized anxiety disorder (GAD), it is essential to consider therapeutic interventions. Encouraging the client to avoid anxiety-provoking situations is not recommended as it can reinforce their anxiety. Teaching relaxation techniques, encouraging the expression of feelings, and providing a structured daily routine are beneficial strategies in managing generalized anxiety disorder by promoting coping skills and emotional expression while fostering stability and predictability.
A client with schizophrenia is experiencing auditory hallucinations. Which intervention should the nurse implement to address this symptom?
- A. Encourage the client to discuss the voices.
- B. Tell the client that the voices are not real.
- C. Provide reality-based feedback to the client.
- D. Distract the client from the voices.
Correct Answer: C
Rationale: When a client with schizophrenia is experiencing auditory hallucinations, providing reality-based feedback is a therapeutic intervention. This helps the client differentiate between what is real and what is not, aiding in reducing the impact of hallucinations. Encouraging the client to discuss the voices may validate the hallucinations, telling the client that the voices are not real dismisses their experience, and distracting the client may not address the underlying issue of the hallucinations.
A client is being taught relaxation techniques to manage anxiety. Which of the following techniques should not be included in the teaching? Select all that apply.
- A. Deep breathing exercises
- B. Progressive muscle relaxation
- C. Mindfulness meditation
- D. Cognitive restructuring
Correct Answer: D
Rationale: Deep breathing exercises, progressive muscle relaxation, and mindfulness meditation are commonly used relaxation techniques to manage anxiety. Cognitive restructuring is a cognitive-behavioral technique aimed at changing negative thought patterns and beliefs, not a relaxation technique. It focuses on altering cognitive distortions rather than inducing physical relaxation responses.
A client is experiencing a panic attack. Which action should the nurse take first?
- A. Remain with the client and offer reassurance.
- B. Administer an anti-anxiety medication as prescribed.
- C. Encourage the client to engage in physical activity.
- D. Encourage the client to breathe deeply and slowly.
Correct Answer: A
Rationale: During a panic attack, the immediate priority for the nurse is to provide support and reassurance to the client. Remaining with the client helps establish a sense of safety and trust, which can help calm the client during an episode of panic. Administering medication, encouraging physical activity, and deep breathing techniques are beneficial interventions, but offering reassurance and support should be the initial step to address the immediate emotional distress and anxiety experienced by the client.
In assessing a client with major depressive disorder, which of the following findings shouldn't the nurse expect?
- 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 typically associated with bipolar disorder during manic episodes, not major depressive disorder.