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A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanisms is the client demonstrating?
- A. Rationalization
- B. Denial
- C. Compensation
- D. Displacement
Correct Answer: C
Rationale: The client is demonstrating the defense mechanism of Compensation. Compensation involves covering up weaknesses by emphasizing strengths in other areas. In this scenario, the client is compensating for feeling inadequate or unappreciated by becoming angry and defensive when his actions are questioned. This behavior serves to divert attention away from his perceived shortcomings and protect his self-esteem.
Rationalization (A) involves creating logical explanations to justify behaviors or feelings. Denial (B) is refusing to acknowledge unpleasant realities. Displacement (D) is redirecting emotions from the real target to a substitute target. In this case, these defense mechanisms are not as applicable as Compensation, which directly relates to the client's behavior of overcompensating for his perceived lack of attention.
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A nurse is caring for a client who has bipolar disorder and is experiencing a manic episode. Which of the following actions should the nurse take?
- A. Place the client in a group therapy session
- B. Rotate staff members who work with the client
- C. Encourage the client to participate in physical activities
- D. Distract the client with increased environmental stimuli
Correct Answer: C
Rationale: The correct answer is C: Encourage the client to participate in physical activities. Physical activities can help to channel the excess energy and agitation associated with manic episodes in bipolar disorder. Exercise can help reduce stress, improve mood, and promote better sleep patterns. Group therapy (A) may not be appropriate during a manic episode as the client may have difficulty focusing and could disrupt the session. Rotating staff members (B) could lead to inconsistency in care and may worsen the client's symptoms. Distracting the client with increased environmental stimuli (D) could exacerbate agitation and overstimulation. It is important to provide a structured and safe outlet for the client's energy, hence physical activities are the most appropriate intervention in this scenario.
A nurse is caring for a client who exhibits excessive compliance, passivity, and self-denial. The nurse should recognize that these findings are associated with which of the following personality disorders?
- A. Dependent
- B. Paranoid
- C. Borderline
- D. Histrionic
Correct Answer: C
Rationale: The correct answer is C: Borderline. Excessive compliance, passivity, and self-denial are characteristic traits of individuals with Borderline Personality Disorder. They often struggle with identity, exhibit intense emotions, and have unstable relationships. Choice A, Dependent Personality Disorder, is characterized by a pervasive psychological dependence on others. Choice B, Paranoid Personality Disorder, involves distrust and suspiciousness. Choice D, Histrionic Personality Disorder, is characterized by attention-seeking behavior and emotional overreaction. Choices E, F, and G are irrelevant. In this scenario, the client's behaviors align most closely with the features of Borderline Personality Disorder.
A nurse is assessing a client who has opioid withdrawal. Which of the following findings should the nurse expect?
- A. Hypotension
- B. Hyperthermia
- C. Insomnia
- D. Bradycardia
Correct Answer: C
Rationale: The correct answer is C: Insomnia. Opioid withdrawal often presents with symptoms like insomnia due to increased sympathetic activity. Hypotension (A) is less likely as opioids can cause hypertension. Hyperthermia (B) is not typically associated with opioid withdrawal. Bradycardia (D) is also less common, as opioid withdrawal can lead to tachycardia. Insomnia is a hallmark symptom of opioid withdrawal, making it the most appropriate choice.
A nurse is reviewing laboratory findings for a client who has been taking lithium for 6 months. Which of the following findings should the nurse report to the provider?
- A. Lithium level 0.8 mEq/L
- B. Sodium 130 mEq/L
- C. Creatinine 1.5 mg/dL
- D. WBC 8,000/mm³
Correct Answer: C
Rationale: The correct answer is C: Creatinine 1.5 mg/dL. This finding should be reported because an elevated creatinine level indicates impaired kidney function, which can lead to lithium toxicity. Lithium is primarily excreted by the kidneys, and impaired renal function can result in lithium accumulation in the body, increasing the risk of adverse effects. Reporting this finding promptly will allow the provider to adjust the dosage of lithium to prevent toxicity.
Choices A, B, and D are within normal ranges and do not directly indicate lithium toxicity. A lithium level of 0.8 mEq/L is within the therapeutic range (0.6-1.2 mEq/L). Sodium level of 130 mEq/L is also within normal limits. WBC count of 8,000/mm³ is normal and not directly related to lithium toxicity. Therefore, these findings do not require immediate reporting compared to the elevated creatinine level.
A nurse is developing a plan of care for a client who has borderline personality disorder and exhibits manipulative behavior. Which of the following interventions should the nurse include?
- A. Encourage flexibility with unit rules
- B. Implement consistent limit-setting
- C. Allow the client to negotiate consequences
- D. Avoid addressing manipulative behavior
Correct Answer: B
Rationale: The correct answer is B: Implement consistent limit-setting. For clients with borderline personality disorder and manipulative behavior, consistent limit-setting helps establish boundaries and promote a sense of security. By enforcing clear and consistent rules, the nurse can prevent manipulation and maintain a therapeutic environment. Encouraging flexibility with unit rules (choice A) may enable manipulation and disrupt the treatment process. Allowing the client to negotiate consequences (choice C) can reinforce manipulative behaviors. Avoiding addressing manipulative behavior (choice D) can lead to escalation and reinforcement of maladaptive behaviors.