Nokea
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.
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A nurse in an acute care mental health facility is sitting with a client who has schizophrenia. The client whispers to the nurse, “I'm being kept in this prison against my will. Please try to get me out.” Which of the following responses should the nurse make?
- A. "Why do you feel that you need to leave?"
- B. "You feel that you don't belong here?"
- C. "We are here to help you and give you the care that you need right now."
- D. "Try to take some deep breaths and I'm sure you'll feel better."
Correct Answer: C
Rationale: The correct response is C: "We are here to help you and give you the care that you need right now." This response acknowledges the client's feelings, reassures them of support, and validates their experience without dismissing their concerns. It promotes a therapeutic relationship and trust-building.
Choice A is incorrect as it does not address the client's immediate distress. Choice B is also incorrect as it may come across as invalidating the client's feelings. Choice D is incorrect as it suggests a quick fix without addressing the client's underlying concerns.
A nurse is reviewing medication records for several psychiatric clients who have bipolar disorder. Which of the following medications is commonly used to treat bipolar disorder?
- A. Paroxetine
- B. Lithium
- C. Donepezil
- D. Valproate
- E. Carbamazepine
Correct Answer: B
Rationale: The correct answer is B: Lithium. Lithium is a mood stabilizer commonly used to treat bipolar disorder by reducing the frequency and intensity of manic episodes. It helps to balance neurotransmitters in the brain. Paroxetine (A) is an antidepressant, Donepezil (C) is used for Alzheimer's disease, Valproate (D) is another mood stabilizer, and Carbamazepine (E) is an anticonvulsant often used in bipolar disorder. Therefore, the correct choice is Lithium (B) as it specifically targets bipolar symptoms.
A nurse in an emergency department is caring for an adolescent client who reports being sexually assaulted just prior to admission. Which of the following actions should the nurse take?
- A. Discuss self-defense techniques with the client.
- B. Inform the client that photographs of injuries are required for a police report.
- C. Ask the client to describe the situation.
- D. Give the client a bed bath prior to physical examination.
Correct Answer: C
Rationale: Allowing the client to provide details at their own pace fosters a sense of control.
A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse identify as a negative symptom?
- A. Delusions
- B. Hallucinations
- C. Social withdrawal
- D. Agitation
- E. Flat affect
Correct Answer: C
Rationale: The correct answer is C: Social withdrawal. Negative symptoms in schizophrenia involve the absence or reduction of normal behaviors or functions. Social withdrawal is a common negative symptom, characterized by the client's lack of interest in social interactions. Delusions (A) and hallucinations (B) are positive symptoms, involving the presence of abnormal behaviors or perceptions. Agitation (D) is a symptom of increased motor activity, not a negative symptom. Flat affect (E) refers to a lack of emotional expression, which is also a negative symptom. In summary, social withdrawal aligns with the definition of negative symptoms in schizophrenia, making it the correct answer.
A nurse is sitting in the day room at an acute care mental health facility with a group of clients who are watching television. Suddenly, one of the clients jumps up screaming and runs out of the room. Which of the following actions should the nurse take?
- A. Ask the group what they think about the client’s behavior.
- B. Follow the client to determine the cause of the behavior.
- C. Ignore the incident because it is an attention-seeking behavior.
- D. Stay with the group and ask another client to check on the situation.
Correct Answer: B
Rationale: The correct answer is B: Follow the client to determine the cause of the behavior. This is the best course of action as the nurse should prioritize the safety and well-being of the client who exhibited distress. By following the client, the nurse can assess the situation, provide immediate assistance if needed, and ensure the client's safety. This proactive approach allows the nurse to address any potential risks or triggers that may have caused the client to react in such a manner.
Choice A is incorrect because seeking the group's opinion may waste time and delay necessary intervention. Choice C is incorrect as ignoring the incident could lead to a potentially dangerous situation being overlooked. Choice D is also incorrect as asking another client to check on the situation may not ensure the client's safety and well-being. The best approach is for the nurse to directly assess the client's needs and respond accordingly.