Nokea
The nurse is caring for a client in the psychiatric unit who has issues with coping and defense mechanisms. The nurse understands that which is true regarding coping and defense mechanisms? Select all that apply.
- A. Coping mechanisms are destructive ways to avoid dealing with reality.
- B. Physical symptoms, general irritability, and self-destructive behaviors are some of the signs of inadequate coping.
- C. Criticizing ineffective defense mechanisms will guide the client toward better coping techniques.
- D. Ineffective coping mechanisms allow anxiety to increase, triggering the client to utilize defense mechanisms in order to protect himself from the anxiety.
- E. The inability to cope can be caused by a lack of an adequate support system, a serious medical diagnosis, situational crises, or a lack of psychological resources.
Correct Answer: B,D,E
Rationale: Coping mechanisms are constructive, not destructive, making A incorrect. Criticizing defense mechanisms is nontherapeutic, making C incorrect. Signs of inadequate coping, anxiety escalation, and causes of poor coping are accurate.
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A client states to the nurse, 'I don't do anything right. I'm such a loser.' Which therapeutic statement should the nurse make to the client?
- A. You don't do anything right?
- B. You do things right all the time.
- C. Can we identify things you do right?
- D. You are not a loser, you are depressed.
Correct Answer: A
Rationale: Option 1 provides the client with the opportunity to verbalize. With this statement, the nurse can learn more about what the client really means by the statement. The remaining options are closed statements and do not encourage the client to explore further.
The nurse provides care for a client receiving haloperidol for 3 days. The client's temperature is 103.5°F (39.7°C), blood pressure 200/100 mm Hg, and pulse 122 beats/min. The client is pale and sweating excessively. Which action does the nurse take first?
- A. Monitor vital signs every 15 minutes.
- B. Administer bromocriptine as prescribed.
- C. Administer the haloperidol as prescribed.
- D. Assess the client's level of consciousness.
Correct Answer: B
Rationale: The symptoms suggest neuroleptic malignant syndrome (NMS), a life-threatening reaction to haloperidol. Administering bromocriptine, if prescribed, is the priority to reverse NMS. Monitoring, continuing haloperidol, or assessing consciousness delays critical intervention.
A family member of a client diagnosed with a brain tumor states that he is feeling distraught and guilty for not encouraging the client to seek medical evaluation earlier. Which information should the nurse incorporate when formulating a response to the family member's statement?
- A. A brain tumor presents with few sights/symptoms.
- B. It is true that brain tumors are easily recognizable.
- C. Brain tumors are never detected until very late in their course.
- D. The signs/symptoms of a brain tumor may be easily attributed to another cause.
Correct Answer: D
Rationale: Signs and symptoms of a brain tumor vary depending on location, and they may easily be attributed to another cause. Symptoms include headache, vomiting, visual disturbances, and changes in intellectual abilities or personality. Seizures occur in some clients. These symptoms can be easily attributed to other causes. The family requires support to assist them during the normal grieving process. Options 1, 2, and 3 are inaccurate statements.
A client is about to undergo a pericardiocentesis to help manage rapidly accumulating pericardial effusion. What is the best plan for the nurse to implement to alleviate the client's apprehension?
- A. Suggesting the client watch television during the procedure as a distraction
- B. Talking to the client from the foot of the bed and assisting with the procedure
- C. Staying beside the client to give information and encouragement during the procedure
- D. Assuring the client that even though there are other clients needing care, the client's needs are most important
Correct Answer: C
Rationale: Clients who develop sudden complications are in situational crisis and need therapeutic intervention. Staying with the client and giving information and encouragement is part of building and maintaining trust in the nurse-client relationship. Options 1 and 4 distance the nurse from the client psychosocially. The nurse should ask another caregiver to be available to assist with the procedure.
A client who has been newly admitted to the mental health unit with a diagnosis of bipolar disorder is trying to organize a dance with the other clients on the unit at suppertime. The nurse should encourage which action to decrease stimulation with the clients?
- A. Seek assistance from other staff members.
- B. Engage the help of other clients on the unit to accomplish the task.
- C. Stop the planning and firmly tell the client that this task is inappropriate.
- D. Postpone organizing the dance and supper and engage the client in a writing activity.
Correct Answer: D
Rationale: Because the client with bipolar disorder is easily stimulated by the environment, sedentary activities are the best outlets for energy release. Most bipolar clients enjoy writing, so the writing task is appropriate. An activity such as planning a dance at suppertime may be appropriate at some point, but not for the newly admitted client who is likely to have impaired judgment and a short attention span. Options 1 and 2 encourage planning the activity, and therefore increase client stimulation. Option 3 could result in an angry outburst by the client.