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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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A charge nurse is admitting a client who has bipolar disorder and who is in the manic phase. Which of the following room assignments should the nurse give the client?
- A. A semi-private room across from the day room.
- B. A private room in a quiet location on the unit.
- C. A private room across from the exercise room.
- D. A semi-private room across from the snack area.
Correct Answer: B
Rationale: The correct answer is B: A private room in a quiet location on the unit. This choice minimizes stimuli and provides a calm environment, essential for managing manic symptoms. A quiet location reduces potential triggers for agitation or impulsivity. Semi-private rooms (A, D) may lead to conflicts with roommates. Rooms near common areas (C, D) can be noisy and disruptive. Overall, choice B promotes client safety and well-being during the manic phase.
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.
A community health nurse is providing teaching to the family of a client who has primary dementia. Which of the following manifestations should the nurse tell the family to expect?
- A. Decreased auditory and visual acuity
- B. Decreased display of emotions
- C. Personality traits that are opposite of original traits
- D. Forgetfulness gradually progressing to disorientation
Correct Answer: D
Rationale: Dementia typically presents with progressive forgetfulness and eventual disorientation.
A nurse in a psychiatric unit is admitting a client who attacked a neighbor. The nurse should know that the client can be kept in the hospital after the 72-hour hold is over for which of the following conditions?
- A. The client is a danger to herself or others.
- B. The client is unwilling to accept that treatment is needed.
- C. The client states that she does not like the neighbor.
- D. The client states that she plans to move out of the state immediately.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: The nurse can keep the client in the hospital after the 72-hour hold if the client is deemed a danger to herself or others. This is crucial in ensuring the safety of the client and others. It indicates that the client poses a significant risk of harm, warranting further evaluation and treatment.
Incorrect Choices:
B: The client's willingness to accept treatment is important, but it does not solely determine if the client can be kept in the hospital.
C: Personal preferences or dislikes are not sufficient reasons to detain a client after the hold is over.
D: Planning to move out of the state does not address the immediate safety concerns that necessitate continued hospitalization.
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.