Nokea
Which client statement should alert a nurse that a client may be responding maladaptively to stress?
- A. I've found that avoiding contact with others helps me cope.
- B. I really enjoy journaling; it's my private time.
- C. I signed up for a yoga class this week.
- D. I made an appointment to meet with a therapist.
Correct Answer: A
Rationale: The correct answer is A. Reliance on social isolation as a coping mechanism is maladaptive and can hinder the development of appropriate coping skills and access to support systems. It may indicate a lack of healthy coping strategies and social connections, which are important for managing stress effectively. Choice B is a positive coping strategy that promotes self-reflection and emotional expression. Choice C reflects a proactive approach to managing stress through physical activity. Choice D shows a willingness to seek professional help, which is a healthy coping mechanism.
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What is the most significant consequence of the excessive use of defense mechanisms?
- A. Suppression of problem-solving skills.
- B. Intense experience of emotions.
- C. Enhancement of learning and growth.
- D. Limitation of problem-solving.
Correct Answer: D
Rationale: The most significant consequence of the excessive use of defense mechanisms is the limitation of problem-solving skills. When individuals rely excessively on defense mechanisms to cope with stress or anxiety, they may avoid addressing underlying issues or seeking healthier coping strategies. This can lead to maladaptive behaviors, hindering their ability to effectively deal with reality, maintain healthy relationships, or perform well in various aspects of life. Choices A, B, and C are incorrect because the suppression of problem-solving skills, intense experience of emotions, and enhancement of learning and growth are not the primary consequences of excessive use of defense mechanisms.
A bright student confides in the school nurse about conflicts related to attending college or working to add needed financial support to the family. Which coping strategy is most appropriate for the nurse to recommend to the student at this time?
- A. Meditation
- B. Problem-solving training
- C. Relaxation
- D. Journaling
Correct Answer: B
Rationale: In this scenario, the student is dealing with conflicting priorities of attending college or working to support the family financially. Problem-solving training is the most appropriate coping strategy to recommend. It can help the student objectively assess the situation, identify potential solutions, and make informed decisions. Problem-solving training provides structure and guidance, empowering the student to navigate the conflicting priorities effectively and choose the best course of action. Meditation, relaxation, and journaling may be beneficial for stress relief but may not directly address the decision-making process required in this situation.
A client with a history of alcohol use disorder is admitted to the hospital for detoxification. Which of the following symptoms should the nurse expect to observe during withdrawal? Select one that doesn't apply.
- A. Tremors
- B. Hallucinations
- C. Diaphoresis
- D. Bradycardia
Correct Answer: D
Rationale: During alcohol withdrawal, symptoms such as tremors, hallucinations, diaphoresis, and seizures are commonly observed. Bradycardia is not typically associated with alcohol withdrawal; instead, tachycardia, an increased heart rate, is more commonly seen. Therefore, bradycardia is the correct answer as it is not an expected symptom during alcohol withdrawal. Tremors, hallucinations, and diaphoresis are all common manifestations of alcohol withdrawal, while bradycardia is not typically seen in this context.
Which is an example of the ego defense mechanism of regression?
- A. A mother blames the teacher for her child's failure in school.
- B. A teenager becomes hysterical after seeing a friend killed in a car accident.
- C. A woman wants to marry a man exactly like her beloved father.
- D. An adult throws a temper tantrum when he does not get his own way.
Correct Answer: D
Rationale: The correct answer is D. Regression involves reverting to an earlier stage of development for comfort. In this case, an adult throwing a temper tantrum is regressing to a childlike behavior when faced with not getting their way, which is a form of seeking comfort associated with earlier development. Choices A, B, and C do not exemplify regression. Blaming the teacher, becoming hysterical after a traumatic event, or seeking a partner similar to a beloved father are not instances of reverting to earlier developmental stages to cope with stress or conflict.
Devastated by a divorce from an abusive husband, a wife completes grief counseling. Which statement by the wife should indicate to a nurse that the client is in the acceptance stage of grief?
- A. If only we could have tried again, things might have worked out.
- B. I am so mad that the children and I had to put up with him as long as we did.
- C. Yes, it was a difficult relationship, but I think I have learned from the experience.
- D. I still don't have any appetite and continue to lose weight.
Correct Answer: C
Rationale: The nurse should recognize that the client is in the acceptance stage of grief based on the statement 'Yes, it was a difficult relationship, but I think I have learned from the experience.' In this statement, the client is acknowledging the difficulty of the relationship but also expressing personal growth and learning from the experience, indicating acceptance. Choices A, B, and D do not reflect the acceptance stage of grief. Choice A shows a sense of regret and a wish for things to have turned out differently. Choice B demonstrates lingering anger towards the ex-husband. Choice D suggests ongoing physical manifestations of grief like loss of appetite and weight loss, which are more indicative of earlier stages of grief.