Nokea
A male client who is participating in an anger management assignment asks if he can make a leather belt in occupational therapy. The client begins pounding the leather vigorously with a mallet to imprint designs on the belt. What defense mechanism is the client using?
- A. Sublimation
- B. Suppression
- C. Regression
- D. Compensation
Correct Answer: A
Rationale: The correct answer is A, Sublimation. Sublimation is a defense mechanism where unacceptable impulses are redirected into socially acceptable activities, such as art or work. In this scenario, the client is channeling his anger into a creative and constructive task like making a leather belt. Choice B, Suppression, involves consciously pushing down or hiding feelings rather than expressing them through alternate means. Choice C, Regression, refers to reverting to earlier, immature behaviors when faced with stress. Choice D, Compensation, involves making up for a perceived weakness in one area by excelling in another, which is not demonstrated in the scenario provided.
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Select the nursing interventions for a hospitalized client with mania who is exhibiting manipulative behavior. Select one intervention that does not apply.
- A. Communicate expected behaviors to the client
- B. Ensure that the client knows that he or she is not in charge of the nursing unit
- C. Assist the client in identifying ways of setting limits on personal behaviors
- D. Follow through about the consequences of behavior in a non-punitive manner
Correct Answer: B
Rationale: The correct answer is B. Ensuring that the client knows they are not in charge of the nursing unit is not a helpful nursing intervention for managing manipulative behavior in a client with mania. Communicating expected behaviors, assisting with limit-setting, and following through on consequences in a non-punitive manner are more appropriate interventions to address manipulative behavior.
The wife of a client diagnosed with paranoid schizophrenia visits 2 days after her husband's admission and states to the nurse, 'Why isn't he eating? He's still talking about his food being poisoned.' Which of the following appraisals by the LPN/LVN is most accurate?
- A. The wife's inquiry is reasonable.
- B. Education about her husband's medication is needed.
- C. Her expectations of her husband are realistic.
- D. An increase in the client's medication is needed.
Correct Answer: B
Rationale: The correct answer is B. The wife needs education about her husband's medication to understand how it affects his perceptions, including paranoid thoughts about food. Choice A is incorrect because the wife's inquiry reflects her lack of understanding of the situation rather than being reasonable. Choice C is incorrect as the husband's condition requires specialized care beyond what the wife might consider realistic. Choice D is incorrect as increasing medication should not be the immediate response; education and reassurance are key in this situation.
The LPN/LVN is caring for a client who is experiencing alcohol withdrawal. Which intervention should the nurse implement first?
- A. Administer a PRN dose of lorazepam (Ativan).
- B. Monitor the client's vital signs.
- C. Place the client on seizure precautions.
- D. Encourage the client to express feelings about withdrawal.
Correct Answer: B
Rationale: When caring for a client experiencing alcohol withdrawal, the first intervention the nurse should implement is to monitor the client's vital signs. Vital sign monitoring is crucial to assess for any potential complications such as hypertension, tachycardia, fever, or other signs of autonomic hyperactivity. Administering medication like lorazepam (Ativan) would come after assessing the vital signs to determine the need for pharmacological intervention. Placing the client on seizure precautions is important, but assessing vital signs takes precedence to ensure immediate safety. Encouraging the client to express feelings about withdrawal is a supportive intervention but does not address the immediate physiological risk associated with alcohol withdrawal.
At the first meeting of a group of older adults at a daycare center for the elderly, the LPN/LVN asks one of the members what kinds of things she would like to do with the group. The older woman shrugs her shoulders and says, 'You tell me, you're the leader.' What is the best response for the nurse to make?
- A. Yes, I am the leader today. Would you like to be the leader tomorrow?
- B. Yes, I will be leading this group. What would you like to accomplish during this time?
- C. Yes, I have been assigned to be the leader of this group. I will be here for the next six weeks.
- D. Yes, I am the leader. You seem angry about not being the leader yourself.
Correct Answer: B
Rationale: The best response for the nurse is choice B: 'Yes, I will be leading this group. What would you like to accomplish during this time?' This response acknowledges the member's comment and encourages her to share her interests, promoting engagement and active participation in group activities. Choice A is not as inclusive and may not foster collaboration within the group. Choice C focuses more on the nurse's assignment rather than addressing the member's input. Choice D assumes emotions that were not expressed by the group member and does not encourage open communication.
A male client is admitted to the mental health unit because he was feeling depressed about the loss of his wife and job. The client has a history of alcohol dependency and admits that he was drinking alcohol 12 hours ago. Vital signs are: temperature, 100 F, pulse 100, and BP 142/100. The nurse plans to give the client lorazepam (Ativan) based on which priority nursing diagnosis?
- A. Risk for injury related to suicidal ideation.
- B. Risk for injury related to alcohol detoxification.
- C. Knowledge deficit related to ineffective coping.
- D. Health-seeking behaviors related to personal crisis.
Correct Answer: B
Rationale: The most important nursing diagnosis is related to alcohol detoxification (B) because the client has elevated vital signs, a sign of alcohol detoxification. Giving lorazepam (Ativan) to address the elevated vital signs due to alcohol withdrawal is a priority. Addressing the risk for injury related to suicidal ideation (A) should come after stabilizing the client's physiological state. Both (C) and (D) can be addressed once immediate safety needs are met, but the priority is managing the alcohol detoxification to prevent potential complications.