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When under stress, a client routinely uses an excessive amount of alcohol. Finding her drunk, her husband yells at her about the chronic alcohol abuse. Which reaction should the nurse recognize as the use of the defense mechanism of denial?
- A. Hiding liquor bottles in a closet
- B. Yelling at their son for slouching in his chair
- C. Burning dinner on purpose
- D. Saying to the spouse, I dont drink too much!
Correct Answer: D
Rationale: The correct answer is D because the client is using denial as a defense mechanism to cope with the stress of being confronted about her alcohol abuse. By saying "I don't drink too much," she is refusing to acknowledge the reality of her excessive alcohol consumption. This denial allows her to avoid facing the uncomfortable truth and the need for change.
A: Hiding liquor bottles in a closet is an example of a defense mechanism called displacement, not denial.
B: Yelling at their son for slouching in his chair is an example of a defense mechanism called projection, not denial.
C: Burning dinner on purpose is an example of a defense mechanism called passive-aggression, not denial.
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During a therapeutic group, two clients engage in an angry verbal exchange. The nurse leader interrupts the exchange and excuses both of the clients from the group. The nurse has demonstrated which leadership style?
- A. Autocratic
- B. Democratic
- C. Laissez-faire
- D. Bureaucratic
Correct Answer: A
Rationale: The correct answer is A: Autocratic. This leadership style is characterized by making decisions independently and enforcing them without input from the group. In this scenario, the nurse leader interrupted the exchange and made the decision to excuse both clients without consulting the group. This approach is necessary in situations requiring immediate intervention to maintain order and ensure the safety of all group members.
Summary of other choices:
B: Democratic - In a democratic leadership style, decisions are made through group discussion and input from all members. This was not demonstrated in the scenario.
C: Laissez-faire - In a laissez-faire leadership style, the leader takes a hands-off approach and allows group members to make decisions. This was not demonstrated as the nurse leader took immediate action.
D: Bureaucratic - Bureaucratic leadership involves following strict rules and procedures. The scenario did not involve following predetermined rules but rather a quick decision made by the nurse leader.
What is the purpose of a nurse providing appropriate feedback?
- A. To give the client good advice
- B. To advise the client on appropriate behaviors
- C. To evaluate the clients behavior
- D. To give the client critical information
Correct Answer: C
Rationale: The purpose of a nurse providing appropriate feedback is to evaluate the client's behavior. This involves assessing the client's actions, understanding their needs, and determining the effectiveness of the care provided. Feedback helps in identifying areas for improvement and guiding the client towards better health outcomes. Choice A is incorrect as feedback is not solely about giving advice. Choice B is incorrect as feedback is not limited to advising on behaviors. Choice D is incorrect as feedback goes beyond just providing critical information to include a holistic evaluation of the client's overall behavior and progress.
An unemployed college graduate is experiencing severe anxiety over not finding a teaching position and has difficulty with independent problem-solving. During a routine physical examination, the graduate confides in the clinic nurse. Which is the most appropriate nursing intervention?
- A. Encourage the student to use the alternative coping mechanism of relaxation exercises.
- B. Complete the problem-solving process for the client.
- C. Work through the problem-solving process with the client.
- D. Encourage the client to keep a journal.
Correct Answer: C
Rationale: The correct answer is C: Work through the problem-solving process with the client. This option promotes empowerment and autonomy by guiding the client to develop their problem-solving skills. It allows the nurse to offer support and guidance without taking over the process entirely, fostering independence and self-efficacy. Encouraging the client to actively participate in finding solutions can help build confidence and improve their ability to handle similar situations in the future.
Explanation for other choices:
A: Encouraging relaxation exercises can be helpful for managing anxiety, but it does not directly address the underlying issue of developing problem-solving skills.
B: Completing the problem-solving process for the client does not empower the client to learn how to address similar challenges independently.
D: Keeping a journal can be a helpful tool for self-reflection and managing emotions, but it does not specifically address the client's difficulty with independent problem-solving.
A nurse is interviewing a distressed client, who relates being fired after 15 years of loyal employment. Which of the following questions would best assist the nurse to determine the clients appraisal of the situation? Select all that apply.
- A. What resources have you used previously in stressful situations?
- B. Have you ever experienced a similar stressful situation?
- C. Who do you think is to blame for this situation?
- D. Why do you think you were fired from your job?
Correct Answer: A
Rationale: The correct answer is A: "What resources have you used previously in stressful situations?" This question is the best choice as it focuses on understanding the client's coping mechanisms and resilience. By asking about previous resources used, the nurse can assess the client's strengths and support systems.
Choice B is incorrect because asking if the client has experienced a similar situation does not directly address the client's current appraisal of the situation.
Choice C is incorrect as it focuses on assigning blame, which may not be helpful in understanding the client's perspective and emotions.
Choice D is also incorrect because asking why the client thinks they were fired may lead to a defensive response and may not necessarily provide insight into the client's appraisal of the situation.
In the role of milieu manager, which activity should the nurse prioritize?
- A. Setting the schedule for the daily unit activities
- B. Evaluating clients for medication effectiveness
- C. Conducting therapeutic group sessions
- D. Searching newly admitted clients for hazardous objects
Correct Answer: D
Rationale: The correct answer is D, searching newly admitted clients for hazardous objects. As a milieu manager, ensuring the safety of clients is a top priority. Searching for hazardous objects upon admission is crucial to prevent harm. Setting schedules (A) can be important but not as urgent as ensuring safety. Evaluating medication effectiveness (B) is important but not the primary role of a milieu manager. Conducting group sessions (C) is valuable for therapy but ensuring physical safety takes precedence.