Nokea
During a one-to-one session with the nurse, a female client admitted for chronic depression and attempted suicide discloses experiences of sexual promiscuity and prostitution. When the nurse asks the client if she was ever sexually abused as a child, the client says, “I don't remember, but my mother ran my father off when I was five.†The nurse should recognize that the client may be using which defense mechanism?
- A. Regression.
- B. Projection.
- C. Denial.
- D. Repression.
Correct Answer: D
Rationale: Repression involves unconsciously blocking out memories, and the client's inability to recall potential abuse suggests this defense mechanism.
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An older man with a history of multiple falls at home tells the clinic nurse that his son, who was incarcerated last year for assault and battery, has become increasingly abusive since his release from prison six weeks ago. Which intervention is most important for the nurse to implement?
- A. Tell the client to call Adult Protective Services if his son's abuse continues.
- B. Verify the client's report by determining if there is physical evidence of abuse.
- C. Refer the client to a program for victims of domestic violence.
- D. Assist the client in developing an emergency safety plan.
Correct Answer: D
Rationale: Assisting the client in developing an emergency safety plan is the most important intervention to ensure immediate safety in the context of ongoing abuse.
The nurse is teaching a group of adolescents about assertive communication. Two of the adolescents are seated at a round table and another is sitting on a small sofa nearby. To facilitate group interaction, which intervention is best for the nurse to implement?
- A. Allow the adolescents to sit wherever they wish as long as they participate.
- B. Suggest that they all sit together to increase interaction.
- C. Ask the adolescent sitting on the couch to join the group at the table.
- D. Determine which adolescents would like to participate in the discussion.
Correct Answer: C
Rationale: Asking the adolescent on the couch to join the table promotes inclusivity and equal participation, enhancing group interaction.
Which interventions should the nurse include in the plan of care for an adolescent who is depressed? (Select all that apply.)
- A. Reinforce statements regarding a will to live and realistic plans for the future.
- B. Discuss the client's suicide plan.
- C. Limit time allowed to play video games.
- D. Encourage the client to discuss thoughts and feelings about wanting to die.
- E. Restrict visitors to family members only.
Correct Answer: A,B,D
Rationale: Reinforcing a will to live, discussing suicide plans, and encouraging expression of suicidal thoughts promote hope, assess risk, and ensure safety.
An adolescent female with an eating disorder is admitted to the in-patient psychiatric unit. Which intervention should the nurse implement?
- A. Encourage the client to weigh herself daily at bedtime.
- B. Recommend exercise and recreation in the morning.
- C. Allow the client to select an arts and crafts activity.
- D. Put the client in charge of choosing snacks for the unit.
Correct Answer: C
Rationale: Allowing the client to select an arts and crafts activity provides a positive, non-food-related outlet for expression, supporting therapeutic engagement.
While assessing a client with the diagnosis of schizophrenia who wears dentures, the nurse observes that the client's tongue is “wormingâ€. The client also demonstrates an inability to articulate words clearly. Which additional assessment is most important for the nurse to obtain?
- A. Usual level of activity and average sleep pattern.
- B. Blood pressure when sitting and standing.
- C. Dentures to determine if they are poorly fitted.
- D. Body weight over the past three months.
Correct Answer: C
Rationale: Assessing the fit of dentures is crucial, as poorly fitted dentures could contribute to speech difficulties and tongue abnormalities observed.