Nokea
A nurse is counseling a client for the management of anxiety. The client is consistently late for appointments and ignores household chores. The client states, "I'm just too stressed. I need someone to take care of me.” The nurse identifies this behavior as an example of which of the following defense mechanisms?
- A. Dissociation
- B. Introjection
- C. Regression
- D. Repression
Correct Answer: C
Rationale: The correct answer is C: Regression. Regression is a defense mechanism where an individual reverts to an earlier stage of development when faced with stressful situations. In this scenario, the client's behavior of being consistently late and avoiding responsibilities reflects a regression to a state where they feel the need to be taken care of, like a child seeking comfort from a caregiver. This behavior is a way of coping with anxiety by seeking refuge in a familiar and less demanding role. Dissociation (A) involves disconnecting from reality to avoid distress, introjection (B) is internalizing the qualities of others, and repression (D) is unconsciously suppressing unwanted thoughts or memories.
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A nurse is assessing a client who is experiencing chronic stress. Which of the following findings should the nurse expect?
- A. Hypotension
- B. Viral infection
- C. Increased energy
- D. Increased cognitive awareness
Correct Answer: B
Rationale: The correct answer is B: Viral infection. Chronic stress weakens the immune system, making the individual more susceptible to infections like viral illnesses. This is due to the prolonged release of stress hormones, which suppress immune function. Hypotension (A) is unlikely as stress typically raises blood pressure. Increased energy (C) is less likely as chronic stress often leads to fatigue. Increased cognitive awareness (D) is not a common finding with chronic stress, as it can impair cognitive function.
A nurse is caring for a hospitalized client who tells lies about other clients. The other clients on the unit frequently complain about the client's disruptive behaviors. Which of the following initial actions should the nurse take?
- A. Talk to the nursing staff.
- B. Talk to the client and identify the specific limits that are required of the client's behavior.
- C. Discuss the problem in a community meeting with the other clients on the unit present.
- D. Escort the client to her room each time the nurse observes the client socializing with others.
Correct Answer: B
Rationale: The correct initial action for the nurse to take is choice B: Talk to the client and identify the specific limits that are required of the client's behavior. This option is the most appropriate because it directly addresses the client's behavior and sets clear expectations. By having a one-on-one conversation with the client, the nurse can establish boundaries and consequences for disruptive behavior, which may help modify the client's actions. Talking to the nursing staff (choice A) may be necessary later, but addressing the client directly is the first step. Discussing the problem in a community meeting (choice C) may embarrass the client and not address the behavior directly. Escorting the client to her room (choice D) does not address the underlying issue of lying and disruptive behavior.
A nurse in a mental health clinic is conducting a staff education session on schizophrenia. Which of the following manifestations should the nurse identify as negative symptoms? (Select all that apply.)
- A. Delusions
- B. Hallucinations
- C. Anhedonia
- D. Poor judgment
- E. Blunt affect
Correct Answer: C, E
Rationale: The correct manifestations for negative symptoms of schizophrenia are C: Anhedonia and E: Blunt affect. Anhedonia refers to the inability to feel pleasure, which is a common negative symptom. Blunt affect is a reduction in the range and intensity of emotional expression, another classic negative symptom. Delusions (A) and hallucinations (B) are positive symptoms involving distorted perceptions and beliefs. Poor judgment (D) is a cognitive symptom, not specific to schizophrenia. The absence of options F and G means they are not applicable to this question.
A home-health nurse is assessing a client who has obsessive-compulsive disorder (OCD) and finds that the client demonstrates constant repetitive cleaning. The nurse knows that this behavior is an attempt to accomplish which of the following?
- A. Decrease anxiety
- B. Prevent aggressive and impulsive behaviors
- C. Manipulate others
- D. Decrease the time available for interaction with people
Correct Answer: A
Rationale: The correct answer is A: Decrease anxiety. The repetitive cleaning behavior in OCD is a manifestation of the client's attempt to reduce anxiety caused by intrusive thoughts or obsessions. This behavior provides temporary relief from anxiety by creating a sense of control. Choice B is incorrect because OCD cleaning behaviors are not primarily aimed at preventing aggressive or impulsive behaviors. Choice C is incorrect as the cleaning behavior is not typically a form of manipulation. Choice D is incorrect as the primary goal of the behavior is not to decrease interaction time but to manage anxiety.
A nurse is assessing a family as a system. Which of the following factors should the nurse include when assessing sociocultural context?
- A. The sense of self among individual family members
- B. The future goals of the family
- C. The roles of family members
- D. The family's religious practices
Correct Answer: D
Rationale: The correct answer is D: The family's religious practices. When assessing sociocultural context, understanding the family's religious practices is essential as it influences beliefs, values, behaviors, and interactions within the family system. Religious practices can shape decision-making processes and coping strategies. A: The sense of self focuses on individual identity rather than the collective family system. B: Future goals pertain to the family's aspirations and plans, which are important but not directly related to sociocultural context. C: Roles of family members are significant in understanding family dynamics but do not capture the broader sociocultural influences.