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A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanisms is the client demonstrating?
- A. Rationalization
- B. Denial
- C. Compensation
- D. Displacement
Correct Answer: C
Rationale: The client is demonstrating the defense mechanism of Compensation. Compensation involves covering up weaknesses by emphasizing strengths in other areas. In this scenario, the client is compensating for feeling inadequate or unappreciated by becoming angry and defensive when his actions are questioned. This behavior serves to divert attention away from his perceived shortcomings and protect his self-esteem.
Rationalization (A) involves creating logical explanations to justify behaviors or feelings. Denial (B) is refusing to acknowledge unpleasant realities. Displacement (D) is redirecting emotions from the real target to a substitute target. In this case, these defense mechanisms are not as applicable as Compensation, which directly relates to the client's behavior of overcompensating for his perceived lack of attention.
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A nurse is providing behavioral therapy for a client who has obsessive-compulsive disorder. The client repeatedly checks that the doors are locked at night. Which of the following instructions should the nurse give the client when using thought stopping technique?
- A. Keep a journal of how often you check the locks each night
- B. Snap a rubber band on your wrist when you think about checking the locks
- C. Ask a family member to check the lock for you at night
- D. Focus on abdominal breathing whenever you go to check the locks
Correct Answer: B
Rationale: The correct answer is B: Snap a rubber band on your wrist when you think about checking the locks. This is an effective use of thought stopping technique as it creates a physical distraction and discomfort when the client has obsessive thoughts. It helps interrupt the pattern of behavior and redirects the client's focus away from the compulsion. Keeping a journal (A) may increase anxiety and reinforce the behavior. Asking a family member to check the lock (C) doesn't address the client's need to manage their own thoughts and behaviors. Focusing on abdominal breathing (D) may be a relaxation technique but doesn't directly address the obsessive thoughts.
A nurse in a psychiatric facility is planning care for a client who has depression and is at risk for suicide. Which of the following interventions should the nurse implement?
- A. Assign the same staff to the client each shift
- B. Keep the client's room well-lit at all times
- C. Allow the client privacy at all times
- D. Provide access to sharp objects
Correct Answer: A
Rationale: The correct answer is A: Assign the same staff to the client each shift. Consistency in staff helps build trust and rapport, crucial for clients with depression and suicide risk. This continuity allows staff to better monitor the client's behavior, mood changes, and suicide risk factors. The familiarity also helps in identifying early warning signs and implementing appropriate interventions promptly.
Choice B is incorrect because while keeping the room well-lit may help prevent self-harm, it does not address the underlying need for consistent support and monitoring.
Choice C is incorrect as constant privacy may hinder the nurse's ability to assess the client's safety and intervene effectively.
Choice D is incorrect as providing access to sharp objects increases the client's risk of self-harm.
A nurse is preparing to administer chlorpromazine hydrochloride 25 mg PO to an older adult client. Available is chlorpromazine hydrochloride syrup 10 mg/5 mL. How many mL should the nurse administer?
- A. 12.5
- B. 10
- C. 15
- D. 5
Correct Answer: A
Rationale: The correct answer is A: 12.5 mL. To calculate this, we first determine the total amount needed, which is 25 mg. Then, we use the concentration of the syrup, which is 10 mg/5 mL. By setting up a proportion (25 mg = x mL), we can cross multiply to find x, which equals 12.5 mL. Choice B (10 mL) is incorrect because it does not provide the full 25 mg dose. Choices C (15 mL) and D (5 mL) are incorrect as they do not align with the calculated dose based on the concentration of the syrup.
A nurse is reviewing laboratory findings for a client who has been taking lithium for 6 months. Which of the following findings should the nurse report to the provider?
- A. Lithium level 0.8 mEq/L
- B. Sodium 130 mEq/L
- C. Creatinine 1.5 mg/dL
- D. WBC 8,000/mm³
Correct Answer: C
Rationale: The correct answer is C: Creatinine 1.5 mg/dL. This finding should be reported because an elevated creatinine level indicates impaired kidney function, which can lead to lithium toxicity. Lithium is primarily excreted by the kidneys, and impaired renal function can result in lithium accumulation in the body, increasing the risk of adverse effects. Reporting this finding promptly will allow the provider to adjust the dosage of lithium to prevent toxicity.
Choices A, B, and D are within normal ranges and do not directly indicate lithium toxicity. A lithium level of 0.8 mEq/L is within the therapeutic range (0.6-1.2 mEq/L). Sodium level of 130 mEq/L is also within normal limits. WBC count of 8,000/mm³ is normal and not directly related to lithium toxicity. Therefore, these findings do not require immediate reporting compared to the elevated creatinine level.
A nurse in a provider’s office is assessing a school-age child who has a spiral fracture. The parent of the child provides different accounts for the cause of the injury. Which of the following actions should the nurse take first?
- A. Request that the parent leaves the room while you interview the child
- B. Report suspected abuse to child protective services
- C. Ask the child how the injury occurred
- D. Determine the immediate safety needs of the child
Correct Answer: B
Rationale: Correct Answer: B. Report suspected abuse to child protective services.
Rationale: Reporting suspected abuse to child protective services is the first step to ensure the safety and well-being of the child. In cases of conflicting stories from the parent and the child, it is crucial to prioritize the child's safety. Child protective services can investigate further to determine the true cause of the injury and provide necessary support and protection for the child.
Summary of other choices:
A: Requesting the parent to leave the room may be necessary for further assessment, but ensuring the child's safety is the priority.
C: Asking the child how the injury occurred is important but should come after ensuring the child's immediate safety.
D: Determining the immediate safety needs of the child is crucial, but reporting suspected abuse takes precedence to address potential harm.