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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 don't drink too much!'
Correct Answer: D
Rationale: The nurse should recognize the client's statement 'I don't drink too much!' as the use of the defense mechanism of denial. This response indicates the client's refusal to acknowledge the reality of excessive alcohol consumption, which is a key characteristic of denial. By denying the problem, the client avoids facing the negative consequences and feelings associated with their alcohol abuse. Choices A, B, and C do not exhibit denial but rather represent different defense mechanisms. Hiding liquor bottles in a closet might indicate the defense mechanism of concealment, yelling at their son for slouching in his chair could reflect displacement, and burning dinner on purpose might suggest passive-aggressive behavior.
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Which statement about the concept of psychoses is most accurate?
- A. Individuals experiencing psychoses are aware that their behaviors are maladaptive.
- B. Individuals experiencing psychoses experience little distress.
- C. Individuals experiencing psychoses are aware of experiencing psychological problems.
- D. Individuals experiencing psychoses are based in reality.
Correct Answer: B
Rationale: The most accurate statement about psychoses is that individuals experiencing it often exhibit limited distress because they are not fully aware of their altered perception of reality. They may not recognize that their behaviors are maladaptive or acknowledge the presence of psychological issues. Choice A is incorrect because individuals with psychoses may not be aware that their behaviors are maladaptive. Choice C is incorrect because individuals with psychoses may not have insight into their psychological problems. Choice D is incorrect because individuals with psychoses often struggle to differentiate between reality and their altered perceptions.
When a husband accuses his wife of infidelity, which situation would indicate to the nurse the husband's use of the ego defense mechanism of projection?
- A. The husband cries and stamps his feet, demanding that his wife be true to her marriage vows.
- B. The husband ignores the wife's continued absence from the home.
- C. The husband has already admitted to having an affair with a coworker.
- D. The husband takes out his marital frustrations through employee abuse.
Correct Answer: C
Rationale: Projection is a defense mechanism where one attributes their unacceptable feelings or impulses to another person. In this scenario, the husband, by admitting to having an affair with a coworker, is projecting his infidelity onto his wife, indicating the use of the projection defense mechanism. Choice A is incorrect as it describes a different behavior, not projection. Choice B does not demonstrate projection but rather avoidance or denial. Choice D shows displacement of aggression, not projection.
A school nurse is assessing a female high school student who is overly concerned about her appearance. The client's mother states, 'That's not something to be stressed about!' Which is the most appropriate nursing response?
- A. Teenagers! They don't know a thing about real stress.
- B. Stress occurs only when there is a loss.
- C. When you are in poor physical condition, you can't experience psychological well-being.
- D. Stress can be psychological. A threat to self-esteem may result in high stress levels.
Correct Answer: D
Rationale: The correct answer is D. Stress can manifest as physical or psychological. A perceived threat to self-esteem can be as stressful as a physiological change. Choice A is dismissive of the teenager's concerns and does not address the issue professionally. Choice B is incorrect as stress can result from various factors, not just loss. Choice C oversimplifies the relationship between physical condition and psychological well-being, neglecting the impact of mental stressors on overall health.
A healthcare professional is caring for a patient with bipolar disorder who is experiencing a manic episode. Which intervention is most appropriate?
- A. Encourage group activities to increase socialization.
- B. Provide a structured environment with limited stimuli.
- C. Allow the patient to engage in physical activities freely.
- D. Give the patient detailed and complex tasks to complete.
Correct Answer: B
Rationale: During a manic episode, individuals with bipolar disorder may have heightened sensitivity to stimuli and may struggle with organization and decision-making. Providing a structured environment with limited stimuli can help reduce triggers and maintain a sense of control for the patient. It is essential to create a calm and predictable setting to support the individual in managing their symptoms effectively. Choice A is incorrect as group activities may overwhelm the patient due to increased stimuli. Choice C is not the most appropriate because unstructured physical activities may exacerbate the manic symptoms. Choice D is not recommended as detailed and complex tasks can be overwhelming and may contribute to increased stress and agitation in a manic episode.
A client with obsessive-compulsive disorder (OCD) is being cared for by a nurse. Which intervention should the nurse include in the plan of care?
- A. Encourage the client to suppress compulsive behaviors.
- B. Set strict limits on the amount of time the client can engage in compulsive behaviors.
- C. Allow the client to perform compulsive behaviors as needed.
- D. Gradually limit the amount of time allotted for compulsive behaviors.
Correct Answer: D
Rationale: In caring for a client with OCD, it is essential to gradually limit the time allotted for compulsive behaviors. This intervention helps the client develop alternative coping mechanisms. Encouraging suppression or setting strict limits on compulsive behaviors can exacerbate the client's anxiety, making it crucial to approach the care plan with a gradual reduction strategy. Allowing the client to perform compulsive behaviors as needed does not promote progress towards managing OCD symptoms and may reinforce maladaptive patterns of behavior.