Nokea
A twenty-eight-year-old client enters the family therapy meeting clutching a blanket and holds the blanket throughout the session while rocking back and forth in the chair. What defense mechanism is the client demonstrating?
- A. denial
- B. projection
- C. undoing
- D. regression
Correct Answer: D
Rationale: The correct answer is D: regression. The client clutching a blanket and rocking back and forth indicate a return to an earlier stage of development to cope with stress or anxiety. Regression involves reverting to behaviors from a less mature stage. Denial (A) involves refusing to acknowledge reality, projection (B) involves attributing one's feelings onto others, and undoing (C) involves trying to undo or reverse an unacceptable action or thought. These defense mechanisms do not align with the client's behavior of regression.
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A patient whose history includes experiences with abusive partners is being treated for major depressive disorder. The patient's care plan includes rape-trauma syndrome among its nursing diagnoses. What goal is directly associated with this diagnosis?
- A. Remains free from self-harm
- B. Wears appropriate clothing
- C. Reports feeling stronger and having a sense of hopefulness
- D. Demonstrates appropriate affect for both positive and negative emotions
Correct Answer: C
Rationale: The correct answer is C: Reports feeling stronger and having a sense of hopefulness. This goal is directly associated with rape-trauma syndrome as it focuses on the patient's emotional healing and empowerment. By reporting feeling stronger and having hope, the patient is demonstrating progress towards recovery from the trauma. Choice A is incorrect because remaining free from self-harm is more related to monitoring safety rather than addressing the emotional impact of the trauma. Choice B is irrelevant as wearing appropriate clothing does not directly address the emotional healing process. Choice D is incorrect as demonstrating appropriate affect does not specifically target the psychological aspect of overcoming trauma.
A client on a psychiatric unit says,"It's a waste of time to be here. I can't talk to you or anyone." Which would be an appropriate therapeutic nursing response?
- A. "I find that hard to believe."
- B. "Are you feeling that no one understands?"
- C. "I think you should calm down and look on the positive side."
- D. "Our staff here is excellent, and you are in good hands."
Correct Answer: B
Rationale: The correct answer is B because it demonstrates empathy and encourages the client to express their feelings. By asking if the client feels that no one understands, the nurse acknowledges the client's emotions and opens the door for further discussion. Choice A is confrontational and may make the client defensive. Choice C dismisses the client's feelings and is not validating. Choice D is a vague reassurance that does not address the client's concerns.
The nurse is working with a patient whose mobility is impaired secondary to a fall that resulted in a broken hip. In addition, the patient, who has diabetes, is developing problems with vision and hearing. The patient seems increasingly withdrawn and depressed. The nurse determines that the patient is at risk for spiritual distress. Which intervention would be most appropriate?
- A. Encourage the patient to talk about significant childhood religious experiences.
- B. Offer to take the patient to a revival the nurse's church is holding in the community.
- C. Read to the patient Bible passages that seem particularly relevant to the patient's case.
- D. Explore what the mobility, sight, and hearing changes mean to the patient.
Correct Answer: D
Rationale: The correct answer is D because exploring the impact of the mobility, sight, and hearing changes on the patient allows the nurse to address the patient's holistic needs, including spiritual distress. By understanding the patient's perspective on these changes, the nurse can provide support tailored to the patient's concerns, fostering a sense of connection and understanding.
Choice A is incorrect because focusing solely on childhood religious experiences may not address the current issues the patient is facing. Choice B is inappropriate as it imposes the nurse's religious beliefs on the patient. Choice C is also incorrect as it assumes a specific religious approach without considering the patient's individual beliefs and needs.
During a therapy session, a patient is asked to rate the intensity of his current issue from 1 to 10 with 1 being complete absence of the issue and 10 being the most intense. The patient is being asked which type of question?
- A. Relationship
- B. Miracle
- C. Scaling
- D. Exception
Correct Answer: C
Rationale: The correct answer is C: Scaling. Scaling questions involve asking clients to rate the intensity of their issues on a numerical scale, just like in this scenario. This helps therapists understand the perceived severity of the problem and track changes over time. Relationship questions focus on interpersonal dynamics, miracle questions explore ideal outcomes, and exception questions inquire about times when the issue is not present. In this case, the question about rating intensity aligns best with the scaling technique.
Which statement made by the patient demonstrates an understanding of the treatment of choice for patients managing the effects of traumatic events?
- A. I attend my therapy sessions regularly.
- B. Those intrusive memories are hidden for a reason and should stay hidden.
- C. Keeping busy is the key to getting mentally healthy.
- D. I've agreed to move in with my parents so I'll get the support I need.
Correct Answer: A
Rationale: The correct answer is A because attending therapy sessions regularly is a key component of treatment for managing the effects of traumatic events. Regular therapy sessions help individuals process their trauma, develop coping strategies, and work towards healing. Choice B is incorrect as suppressing intrusive memories can worsen mental health. Choice C is incorrect as keeping busy may serve as a distraction but does not address the root cause of trauma. Choice D is incorrect as moving in with parents for support is helpful, but therapy is the evidence-based treatment for trauma management.