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A nurse is caring for a client who has a new diagnosis of cancer. The client states
- A. I can't think about my health until after my son is married next week.' The nurse should identify the client's statement as an indication of which of the following maladaptive defense mechanisms?
- B. Splitting.
- C. Suppression.
- D. Reaction formation.
- E. Projection.
Correct Answer: B
Rationale: Suppression is a conscious decision to delay dealing with stressors, as the client does by focusing on their son’s wedding before addressing their health. This is maladaptive when it delays necessary action.
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A nurse is collecting data from a client who has schizophrenia. Which of the following client statements indicates that the client is experiencing a command hallucination?
- A. Can you see these spiders crawling all over me?
- B. The aliens are going to abduct me tonight.
- C. Are you planning to kill me?
- D. The voices told me to quit eating the food here.
Correct Answer: D
Rationale: The statement 'The voices told me to quit eating the food here' is indicative of a command hallucination, where the client hears voices instructing them to take specific actions. This distinguishes it from visual hallucinations or delusions.
A nurse is caring for a client who becomes extremely agitated and asks if they can go to a separate room to be alone for an hour. The nurse should document which of the following de-escalation techniques in the client's medical record?
- A. Therapeutic hold.
- B. Restraint.
- C. Diversion.
- D. Timeout.
Correct Answer: D
Rationale: Timeout allows the client to have a moment away from stimuli to regain control and calm down, which is a recognized de-escalation technique. This matches the client’s request and supports de-escalation efforts.
A nurse in a mental health facility is collecting a blood specimen from a client. The client is hallucinating and states
- A. That looks like a snake
- B. and I won't let it take all of my blood.' Which of the following responses should the nurse make?
- C. I don’t see a snake, but that must be scary for you.
- D. I’m using a syringe to obtain your blood, not a snake.
- E. Your provider requires this blood specimen.
- F. You must be mistaken.
Correct Answer: A
Rationale: Acknowledging the client's fear and providing reassurance without confirming the hallucination helps build trust and reduce anxiety. This empathetic response supports the client’s emotional state.
A nurse is caring for a client who has depression and reports only sleeping a few hours each night. Which of the following instructions should the nurse give the client to promote sleep?
- A. You should drink a glass of wine 1 hour before you go to bed.
- B. You should eat a meal just prior to bedtime.
- C. You should take a nap after lunch.
- D. You should limit yourself to two caffeinated beverages per day.
Correct Answer: D
Rationale: Limiting caffeine intake to two beverages per day can promote better sleep. Caffeine is a stimulant that can interfere with falling asleep and staying asleep, especially if consumed later in the day. This instruction supports improved sleep quality.
A nurse is collecting data for a health history from a client who has antisocial personality disorder. Which of the following clinical findings is associated with this disorder?
- A. Withdrawn behaviors.
- B. Blunted affect.
- C. Excessively anxious.
- D. Exploitive of others.
Correct Answer: D
Rationale: Exploitive of others is a key characteristic of antisocial personality disorder. Individuals often disregard others’ rights and manipulate them for personal gain, aligning with the disorder’s profile.