Nokea
A nurse at a college campus mental health counseling center is caring for a student who just failed an examination. The student spends the session berating the teacher and the course. The nurse should recognize this behavior as which of the following defense mechanisms?
- A. Conversion
- B. Projection
- C. Undoing
- D. Regression
Correct Answer: B
Rationale: Projection involves attributing one’s own feelings or faults to others.
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A nurse in a psychiatric unit is caring for several clients. Which of the following clients should the nurse recommend for group therapy?
- A. A client who has been taking amitriptyline for 3 months for depression.
- B. A client exhibiting psychotic behavior.
- C. A client admitted 12 hours ago for acute mania.
- D. A client who is experiencing alcohol intoxication.
Correct Answer: A
Rationale: Clients who have stabilized with medication are appropriate for group therapy.
A nurse on an acute mental health unit is caring for a group of clients. For which of the following clients is seclusion contraindicated?
- A. An adult client following a suicide attempt
- B. A school-age client who attempts to repeatedly bite staff
- C. An adolescent client who throws objects at other clients
- D. An older adult client who is manic and crying due to overstimulation
Correct Answer: A
Rationale: Correct Answer: A. Seclusion is contraindicated for an adult client following a suicide attempt. This client may already be in a vulnerable state and seclusion could exacerbate feelings of isolation and hopelessness, potentially leading to further harm. It is important to maintain close observation and provide supportive interventions.
Incorrect Choices:
B: Seclusion may be considered for a school-age client who attempts to bite staff to ensure the safety of both the client and staff.
C: Seclusion may be necessary for an adolescent client who poses a risk to others by throwing objects to prevent harm to self and others.
D: Seclusion may be used for an older adult client who is manic and overstimulated to provide a calm and safe environment for de-escalation.
A nurse is admitting a client who is exhibiting manic behavior. The client reports recent personal stressors including the loss of her mother and a divorce. Which of the following is the priority nursing action?
- A. Identifying support systems.
- B. Assisting the client in identifying coping behaviors.
- C. Encouraging self-care.
- D. Preventing self-directed violence.
Correct Answer: D
Rationale: Safety is the priority for clients experiencing manic episodes, as they are at risk for self-harm.
A nurse is caring for a client who professes a deep and everlasting love for his girlfriend one day and the next day refuses to speak to her or allow her to visit. The nurse recognizes this client behavior as which of the following defense mechanisms?
- A. Repression
- B. Splitting
- C. Sublimation
- D. Undoing
Correct Answer: B
Rationale: Splitting is characterized by viewing things as all good or all bad, commonly seen in personality disorders.
A nurse is caring for a client who has dementia. When performing a Mental Status Examination (MSE), the nurse should include which of the following data? (Select all that apply.)
- A. Ability to perform calculations
- B. Coping skills
- C. Recall ability
- D. Long-term memory
- E. Level of orientation
Correct Answer: A, C, D, E
Rationale: The correct answers are A, C, D, and E. In a Mental Status Examination for a client with dementia, assessing the ability to perform calculations (A) is important to evaluate cognitive function. Recall ability (C) is crucial as memory impairment is a common feature of dementia. Long-term memory (D) is essential to assess for signs of cognitive decline. The level of orientation (E) is vital to determine the client's awareness of time, place, and person, which can be impaired in dementia. Coping skills (B) are important but not typically assessed in an MSE for dementia. The other choices (F, G) do not directly relate to the cognitive impairment typically seen in dementia.