Nokea
The nurse correctly explains to the nursing assistant that this is an example of a client using which coping mechanism?
- A. Introjection
- B. Projection
- C. Compensation
- D. Displacement
Correct Answer: D
Rationale: Displacement involves redirecting emotions, such as anger from a spouse, onto a safer target like the nursing assistant, as seen in the client's behavior.
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The nurse is aware that such attitudes and statements can have damaging consequences for a mentally ill client. What is the most significant consequence of the remark in this situation?
- A. It violates the client's right to treatment.
- B. It disregards the client's individuality.
- C. It interferes with continuity of client care.
- D. It disrupts good staff relationships.
Correct Answer: B
Rationale: Labeling the client as a hypochondriac dismisses their unique experiences, undermining person-centered care and trust.
The nurse manager concerned about the potential for staff harm on a behavioral health unit is assessing the unit’s milieu. Which milieu situation should the nurse manager address because it is a predictive factor for violence?
- A. Two clients have a history of spousal abuse.
- B. Several clients have lost smoking privileges.
- C. The unit is currently at less than full client capacity.
- D. The nurse from a medical unit is assigned to work on the unit.
Correct Answer: D
Rationale: Staff inexperience (D) predicts violence. Client history (A) and privileges (B) are client-focused and low capacity (C) reduces not increases risk.
The nurse is developing the plan of care for the client diagnosed with schizophrenia who is having an alcohol-induced crisis. Which specific client outcome best reflects the primary goal of crisis intervention for this client?
- A. Client will be successfully detoxified within 20 days.
- B. Client will return to his or her part-time job within 20 days.
- C. Client will state two effective coping mechanisms prior to discharge.
- D. Client will demonstrate self-administration of medications prior to discharge.
Correct Answer: B
Rationale: Returning to pre-crisis functioning like work (B) is the crisis intervention goal. Detox (A) stating coping mechanisms (C) and medication administration (D) are secondary.
The nurse counsels the team member privately about the inappropriate remark. What is the first step in understanding the behavior of clients?
- A. Understanding one's own behavior
- B. Analyzing what motivates clients' behavior
- C. Becoming more familiar with abnormal behavior
- D. Taking courses in counseling
Correct Answer: A
Rationale: Self-awareness of personal biases is the first step to understanding client behavior, ensuring objective and empathetic care.
The nurse observes that the client diagnosed with intermittent explosive disorder is becoming aggressive and that lorazepam was prescribed. The client is now exhibiting a tense posture a clenched fist and a defiant affect. Prioritize the nurse’s actions to de-escalate the client’s aggression.
- A. Call other staff for assistance.
- B. Attempt to talk the client down.
- C. Apply wrist restraints.
- D. Offer client choice of taking medication voluntarily.
- E. Provide alternate use of physical energy such as suggesting punching a pillow.
Correct Answer: B ,E ,D ,A, C
Rationale: Talk down (B) builds trust offering physical outlets (E) releases tension medication choice (D) calms staff assistance (A) ensures safety and restraints (C) are last resort for harm prevention.