Nokea
A nurse in an emergency department is assessing a client who has traumatic injuries following an assault. The client sits quietly and calmly in the examination room and states, "I'm fine." The nurse should recognize the client's behavior as which of the following reactions?
- A. Denial
- B. Displacement
- C. Projection
- D. Undoing
Correct Answer: A
Rationale: The correct answer is A: Denial. The client's calm demeanor and statement of "I'm fine" despite having traumatic injuries indicate a defense mechanism of denial, where the client is refusing to acknowledge the severity of their situation. Denial helps the individual cope with overwhelming emotions or stress by avoiding the reality of the situation. Displacement involves redirecting emotions to a less threatening target, projection involves attributing one's thoughts or feelings to others, and undoing involves engaging in behaviors to counteract negative thoughts or actions. In this scenario, denial is the most appropriate reaction based on the client's behavior.
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Which action is most therapeutic for a client with panic-level anxiety?
- A. Suggest the client rest in bed
- B. Remain with the client
- C. Medicate the client with a sedative
- D. Have the client join a therapy group
Correct Answer: B
Rationale: The correct answer is B: Remain with the client. This is the most therapeutic action because it provides immediate reassurance and support to the client, helping to reduce feelings of isolation and fear during a panic attack. By staying with the client, you can offer comfort and help them feel safe and supported.
Choice A is incorrect as suggesting the client rest in bed may not address their immediate needs during a panic attack. Choice C, medicating the client with a sedative, may provide short-term relief but does not address the underlying causes of the anxiety. Choice D, having the client join a therapy group, is not suitable during a panic attack as the client needs immediate support and intervention.
A nurse on a crisis hotline is speaking to a client who says, "I just took an entire bottle of amitriptyline." Which of the following responses should the nurse make?
- A. "I'm glad you called, and I want to send an ambulance to help you."
- B. "You must have been feeling pretty depressed to do that."
- C. "Do you know how many pills were in the bottle?"
- D. "Were you trying to kill yourself by taking an overdose?"
Correct Answer: A
Rationale: The correct response is A: "I'm glad you called, and I want to send an ambulance to help you." This answer demonstrates immediate concern for the client's well-being and prioritizes getting them the necessary medical help. It acknowledges the seriousness of the situation and the potential danger of taking an entire bottle of medication. Sending an ambulance ensures that the client receives prompt medical attention, which is crucial in cases of overdose.
Incorrect responses:
B: "You must have been feeling pretty depressed to do that." - This response focuses on the client's emotional state rather than addressing the immediate need for medical assistance.
C: "Do you know how many pills were in the bottle?" - This question does not prioritize the urgency of the situation and does not address the immediate need for medical help.
D: "Were you trying to kill yourself by taking an overdose?" - This response may come off as accusatory and could potentially escalate the situation. It is important to prioritize the client's safety and well-being
A nurse is caring for a client who has a depressive disorder. The client states, "I just can't feel any happiness or joy in life." Which of the following terms should the nurse use when documenting this finding?
- A. Anhedonia
- B. Anergia
- C. Anosognosia
- D. Akathisia
Correct Answer: A
Rationale: The correct answer is A: Anhedonia. Anhedonia refers to the inability to experience pleasure or joy, which is a common symptom of depressive disorders. In this case, the client's statement of not feeling happiness or joy directly aligns with the definition of anhedonia.
Choice B, Anergia, refers to lack of energy or motivation, which is not directly related to the client's statement about not feeling happiness or joy. Choice C, Anosognosia, is a lack of awareness or insight into one's own condition, which is not applicable in this scenario. Choice D, Akathisia, refers to a movement disorder characterized by restlessness, which is not related to the client's emotional state.
In summary, Anhedonia is the most appropriate term to use when documenting the client's inability to feel happiness or joy, as it directly reflects their emotional experience in the context of a depressive disorder.
A nurse is planning care for a client who demonstrates manipulative behavior. Which of the following actions should be included in the plan of care?
- A. Allow manipulation so as to not raise the client’s anxiety.
- B. Avoid discussing past behaviors with the client.
- C. Bargain with the client to discourage manipulative behavior.
- D. Set clear and consistent limits on manipulative behaviors.
Correct Answer: D
Rationale: The correct answer is D: Set clear and consistent limits on manipulative behaviors. By setting clear boundaries, the nurse establishes a structured environment that promotes accountability and helps the client understand appropriate behavior. This method reinforces boundaries and helps the client learn to interact in a healthier way.
Explanation for other choices:
A: Allowing manipulation does not address the underlying issue and may enable further manipulative behavior.
B: Avoiding discussing past behaviors hinders the therapeutic process and may prevent understanding and resolution of manipulative tendencies.
C: Bargaining with the client only reinforces manipulative behavior and does not address the root cause.
In summary, setting clear and consistent limits is the most effective approach in managing manipulative behavior.
A nurse is caring for a client who is having difficulty sleeping and is pacing the floor. The client’s head is down, and he is wringing his hands. Which of the following actions should the nurse take?
- A. Encourage the client to go back to bed.
- B. Give the client a PRN sleeping medication.
- C. Remain with the client.
- D. Explore alternatives to pacing the floor with the client.
Correct Answer: C
Rationale: The correct answer is C: Remain with the client. By remaining with the client, the nurse can provide support and reassurance, assess the client's emotional state, and ensure the client's safety. This action shows empathy and promotes therapeutic communication. Encouraging the client to go back to bed (A) may not address the underlying issue causing the restlessness. Giving a PRN sleeping medication (B) without further assessment may not be appropriate and could mask the client's feelings. Exploring alternatives to pacing (D) is a good intervention but should come after providing immediate support and understanding the client's needs.