Nokea
Which defense mechanism would the nurse conclude a female client with obsessive-compulsive disorder, who washes her hands more than 20 times a day, is using to ease anxiety?
- A. Undoing
- B. Projection
- C. Introjection
- D. Displacement
Correct Answer: A
Rationale: The correct answer is 'Undoing.' Undoing is a defense mechanism where the individual tries to negate a previous act to relieve guilt or anxiety. In this case, the client washing her hands excessively is trying to 'undo' perceived contamination or guilt associated with not washing. Projection (choice B) involves attributing one's own unacceptable thoughts or impulses to others, which is not demonstrated in this scenario. Introjection (choice C) is the process of internalizing beliefs or values of others, which is also not applicable in this context. Displacement (choice D) involves redirecting emotions from one target to another, which does not align with the client's behavior of handwashing as a response to anxiety in this case.
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A neonatal intensive care nurse is caring for a newborn with a suspected diagnosis of erythroblastosis fetalis. Which therapeutic statement should the nurse make to the parents at this time?
- A. Your infant is very sick. The next 24 hours are the most crucial.'
- B. This is a common neonatal problem, so the prognosis is very good.'
- C. You have reason to worry but we have everything needed to care for your baby right here in this hospital.'
- D. You must have many concerns. Please ask me any questions that you have so that I can explain your infant's care.'
Correct Answer: D
Rationale: The nurse should use therapeutic communication to address the parents' concerns and provide an opportunity for them to ask questions about their infant's care. Option 4 encourages open dialogue and supports the parents emotionally, which is critical during this stressful time. Option 1 may heighten anxiety without offering constructive support. Option 2 inaccurately minimizes the severity of erythroblastosis fetalis. Option 3 acknowledges worry but focuses on hospital resources rather than addressing the parents' emotional needs directly.
The nurse is performing an assessment on a 16-year-old client who has been diagnosed with anorexia nervosa. Which statement by the client should the nurse identify as a priority requiring a need for further teaching?
- A. I check my weight every day without fail.'
- B. I exercise 3 to 4 hours every day to keep my slim figure.'
- C. I've been told that I am 10% below my ideal body weight.'
- D. My best friend was in the hospital with this disorder a year ago.'
Correct Answer: B
Rationale: Exercising 3 to 4 hours every day is excessive physical activity and unrealistic for a 16-year-old girl. The nurse needs to further assess this statement immediately to find out why the client feels the need to exercise this much to maintain her figure. It is not considered abnormal to check the weight every day; many clients with anorexia nervosa check their weight close to 20 times a day. A weight that exceeds 15% below the ideal weight is significant for clients with anorexia nervosa. Although it is unfortunate that the client's best friend had this disorder, this is not considered a major threat to this client's physical well-being.
The best way for a healthcare provider and a healthcare facility to control the effects of poor and disruptive patient behavior is to _________________.
- A. prevent it
- B. restrain the patient
- C. medicate the patient
- D. isolate the patient
Correct Answer: A
Rationale: The most effective approach to managing poor and disruptive patient behavior is by preventing it proactively. This involves implementing strategies, communication techniques, and environmental modifications that address the underlying causes of the behavior. Restraint, medication, and isolation should only be used as a last resort when the patient or others are at risk of harm. Restraint and isolation are primarily used to ensure safety, while medication, especially when used solely to control behavior, can have adverse effects and is considered a measure of last resort. Therefore, prevention is crucial in promoting a therapeutic environment and fostering positive patient outcomes.
The nurse in the psychiatric day program provides care for a client diagnosed with recurrent depression. In doing the initial assessment based on the therapist's recommendation for a cognitive approach to therapy, which aspect is important for the nurse to evaluate?
- A. The client's use of language.
- B. The client's insight into the depression.
- C. The client's socialization history and skills.
- D. The client's attitude toward medications.
Correct Answer: B
Rationale: Cognitive therapy focuses on thought patterns and self-awareness. Evaluating the client's insight into their depression is critical to assess their understanding of their condition and tailor therapy effectively. Other aspects are less directly tied to cognitive approaches.
A client dies while several family members are in the room. Which intervention will the hospice nurse initially use during the shock phase of a grief reaction?
- A. Stay at the bedside with the family and the deceased.
- B. Direct activities related to funeral arrangements.
- C. Mobilize the support systems for the family.
- D. Present the full reality of the loss to the family.
Correct Answer: A
Rationale: During the shock phase of a grief reaction, the hospice nurse's initial intervention should be to stay at the bedside with the family and the deceased. This action provides immediate support to the family until coping mechanisms and personal support systems can be mobilized. Directing activities related to funeral arrangements is not within the nurse's role and responsibility. Mobilizing the support systems for the family is important, but staying with the family and the deceased helps in providing immediate comfort and support. Presenting the full reality of the loss to the family is not appropriate during the shock phase as acceptance of the loss takes time and is not the immediate priority.