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Which is a correct evaluation of the new psychiatric nurse's statement regarding a client's use of defense mechanisms?
- A. Defense mechanisms can be self-protective responses to stress and need not be eliminated.
- B. Defense mechanisms are a maladaptive attempt by the ego to manage anxiety and should always be eliminated.
- C. Defense mechanisms, used by individuals with weak ego integrity, should be discouraged but not eliminated.
- D. Defense mechanisms cause disintegration of the ego and should be fostered and encouraged.
Correct Answer: A
Rationale: The correct evaluation is that defense mechanisms can be self-protective responses to stress and do not necessarily need to be eliminated. These mechanisms serve the purpose of reducing anxiety during times of stress. While some defense mechanisms may be maladaptive, they can also help individuals cope with challenging situations. It is essential for the nurse to recognize that addressing defense mechanisms should be done sensitively, as they may be crucial for the client's emotional regulation. Encouraging the development of healthy coping skills while acknowledging the role of defense mechanisms in managing stress is a balanced approach in psychiatric care. Choice B is incorrect because completely eliminating defense mechanisms is not always feasible or beneficial. Choice C is incorrect as it oversimplifies the relationship between defense mechanisms and ego integrity. Choice D is incorrect as it misrepresents the role of defense mechanisms in ego functions.
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A healthcare provider is assessing a client with suspected bipolar disorder. Which of the following findings should the healthcare provider expect? Select one that does not apply.
- A. Periods of elevated mood
- B. Decreased need for sleep
- C. Flight of ideas
- D. Anhedonia
Correct Answer: D
Rationale: Findings in a client with bipolar disorder typically include periods of elevated mood, decreased need for sleep, and flight of ideas. Anhedonia, characterized by the inability to experience pleasure, is more commonly associated with major depressive disorder. Therefore, the healthcare provider should not expect anhedonia in a client with suspected bipolar disorder. The other choices are characteristic features of bipolar disorder, such as mania or hypomania.
A client has been prescribed sertraline (Zoloft) for depression. Which of the following instructions should the nurse include in the discharge teaching?
- A. Take the medication in the morning to avoid daytime drowsiness.
- B. Avoid drinking alcohol while taking this medication.
- C. Take the medication with a full glass of water.
- D. Stop taking the medication if you feel better.
Correct Answer: B
Rationale: The correct instruction for the nurse to include in the discharge teaching is to advise the client to avoid drinking alcohol while taking sertraline (Zoloft). Alcohol can exacerbate the side effects of the medication, such as drowsiness and dizziness, and may also decrease the effectiveness of the treatment for depression. Choice A is incorrect as sertraline is usually taken in the morning. Choice C is not a specific instruction related to the medication. Choice D is incorrect as abruptly stopping sertraline can lead to withdrawal symptoms and should only be done under medical supervision.
A client has been diagnosed with generalized anxiety disorder and expresses worrying about their job, family, and health, feeling a loss of control. What should the nurse do first?
- A. Administer a prescribed antianxiety medication.
- B. Encourage the client to attend a support group.
- C. Identify triggers of the client's anxiety.
- D. Teach the client deep breathing techniques.
Correct Answer: D
Rationale: The initial step for the nurse is to teach the client deep breathing techniques to aid in managing anxiety symptoms. Deep breathing exercises can help the client relax, reduce anxiety levels, and regain a sense of control. This intervention is non-invasive, empowering the client to develop a coping strategy for immediate use when feeling overwhelmed by anxiety. Administering medication (Choice A) should not be the first action unless the client is in severe distress. Encouraging attendance at a support group (Choice B) and identifying triggers of anxiety (Choice C) are important but teaching coping strategies like deep breathing comes first to help the client feel more in control of managing their anxiety.
A client has been prescribed diazepam (Valium) for the treatment of anxiety. Which of the following instructions should the nurse include in the discharge teaching?
- A. Avoid drinking alcohol while taking this medication.
- B. Take the medication with food to avoid stomach upset.
- C. Stop taking the medication if you feel better.
- D. Double the dose if you miss a dose.
Correct Answer: A
Rationale: The correct instruction is to avoid drinking alcohol while taking diazepam (Valium) as it can potentiate the sedative effects and increase the risk of side effects such as drowsiness and dizziness. Taking the medication with food may help reduce stomach upset, but avoiding alcohol is crucial to ensure safe and effective use of diazepam. Choice B is partially correct, as taking the medication with food can indeed help with stomach upset, but it is not as crucial as avoiding alcohol. Choice C is incorrect because abruptly stopping diazepam can lead to withdrawal symptoms and should only be done under medical supervision. Choice D is incorrect as doubling the dose is dangerous and should never be done without healthcare provider approval.
A client diagnosed with borderline personality disorder has been admitted to the psychiatric unit after a suicide attempt. Which of the following actions should the nurse take first?
- A. Encourage the client to express feelings about the suicide attempt.
- B. Place the client on one-to-one observation.
- C. Discuss the client's feelings about the suicide attempt.
- D. Encourage the client to participate in group therapy.
Correct Answer: B
Rationale: The initial priority for the nurse is to ensure the safety of the client. Placing the client on one-to-one observation allows for constant monitoring and intervention if there are any signs of self-harm or a worsening condition. This immediate intervention is crucial to prevent further harm. Options A, C, and D involve therapeutic communication and interventions, which are important but should come after ensuring the client's safety.