QUESTIONS, ANSWERS AND RATIONALES FOR BEST SCORES(LATEST)
1. A nurse in an alcohol treatment facility is caring for a client who states, “My job is so s... [Show More] tressful that the only way I can cope is to drink.” The nurse should recognize that the client is displaying which of the following defense mechanisms?
A. Introjection (Unconscious adoption of the ideas or attitudes of others)
B. Repression
C. Rationalization
D. Intellectualization
Repression
● Unconsciously putting unacceptable ideas, thoughts, and emotions out of awareness
● ADAPTIVE USE: A person preparing to give a speech unconsciously forgets about the time when he was young and kids laughed at him while on stage.
● MALADAPTIVE USE: A person who has a fear of the dentist
Rationalization
● Creating reasonable and acceptable explanations for unacceptable behavior
● ADAPTIVE USE: An adolescent boy says, “she must already have a boyfriend” when rejected by a girl
● MALADAPTIVE USE: A young adult explains he had to drive home from a party after drinking alcohol because he had to feed his dog
Intellectualization
● Separation of emotions and logical facts when analyzing or coping with a situation or event
● ADAPTIVE USE: A law enforcement officer blocks out the emotional aspect of a crime so he can objectively focus on the investigation.
● MALADAPTIVE USE: A person who learns he has a terminal illness focuses on creating a will and financial matters rather than acknowledging his grief.
2. A nurse is obtaining a medical history from a client who is requesting a prescription for bupropion for smoking cessation. Which of the following assessment findings in the client’s history should the nurse report to the provider?
A. Knee arthroplasty 1 month ago
B. Hepatitis B infection
C. Recent head injury (Avoid administering to clients at risk for seizures, such as a client who has a head injury)
D. Hypothyroidism
Bupropion = ATYPICAL ANTIDEPRESSANT, inhibits Dopamine uptake
○ Alternative to SSRIs for clients unable to tolerate sexual dysfunction side effects
○ Complications: Headache, dry mouth, GI distress, constipation, increased heart rate, nausea, restlessness, insomnia
■ Suppression of appetite = weight loss, contraindicated for those who have anorexia or bulimia
3. A nurse is assessing a client who has histrionic personality disorder. Which of the following findings should the nurse expect?
A. Lack of remorse
B. Splitting of staff
C. Attention-seeking
D. Identity disturbance
Histrionic
● “POK POK” - Characterized by emotional attention-seeking behavior, in which the person needs to be the center of attention; often seductive and flirtatious.
4. A nurse is providing teaching to the daughter of an older client who has obsessive-compulsive disorder.
Which of the following statements by the daughter indicates an understanding of the teaching?
A. “I will provide my mother with detailed instructions about how to perform self-care.” (Give simple directions)
B. “I will limit my mother’s clothing choices when she is getting dressed.” (If client is indecisive, limit the client's choices; if client still unable to make a decision, give client one outfit to wear)
C. “I will wake my mother up a couple of times in the night to check on her.”
D. “I will discourage my mother from talking about her physical complaints.”
OCD
● The client attempts to suppress persistent thoughts or urges that cause anxiety through compulsive or obsessive behaviors, such as repetitive hand washing.
● Obsessions or compulsions are time-consuming and result in impaired social and occupational functioning.
5.A nurse is providing crisis intervention for a client who was involved in a violent mass casualty situation in the community. Which of the following actions should the nurse take during the initial session with the client?
A. Identify the client’s usual coping style.
B. Encourage the client to display anger toward the cause of the crisis. (Reduce stress-related manifestations, such as using techniques to alleviate a panic attack)
C. Tell the client that this life will soon return to normal (False assurance)
D. Help the client focus on a wide variety of topics regarding the crisis. (Reduce stress)
6.A charge nurse is orienting a newly licensed nurse and observes the newly licensed nurse imitating her behaviors. The nurse should recognize this behavior as which of the following defense mechanisms?
A. Suppression (Voluntarily denying unpleasant thoughts and feelings)
B. Identification (Conscious or unconscious assumption of the characteristics of another individual or group)
C. Compensation (Emphasizing strengths to make up for weaknesses)
D. Reaction formation (Overcompensating or demonstrating the opposite behavior of what is felt)
7.A nurse in an inpatient mental health facility is assessing a client who has schizophrenia and is taking
haloperidol. Which of the following clinical findings is the nurse’s priority?
A. Insomnia (Sedation)
B. Urinary frequency (Complication → ANTIcholinergic effects) C. High fever (Complication → agranulocytosis)
D. Headache
Other complications: Acute dystonia, Pseudoparkinsonism, Akathisia, Tardive dyskinesia, Neuroendocrine effects (Gynecomastia, Weight gain, Menstrual irregularities), NMS, Orthostatic Hypotension, Sedation, Sexual dysfunction, Skin effects, Liver impairment
8.A nurse in a mental health facility is caring for a client. Which of the following actions should the nurse take during the working phase of the nurse-client relationship?
A. Summarize goals and objectives.
B. Address confidentiality.
C. Promote problem-solving skills.
D. Establish a participation contract
9.A nurse is providing behavioral therapy for a client who has OCD. The client repeatedly checks that the doors are locked at night. Which of the following instructions should the nurse give the client when using thought stopping technique?
A. “Keep a journal of how often you check the locks each night.”
B. “Ask a family member to check the locks for you at night.”
C. “Focus on abdominal breathing whenever you go to check the locks.”
D. “Snap a rubber band on your wrist when you think about checking the locks.”
Thought stopping: teach pt to say “stop” when negative thoughts/compulsive behaviors arise & substitute positive thought - goal for pt use command silently over time
10.A nurse is assisting with obtaining informed consent for a client who has been legally incompetent. Which of the following actions should the nurse take?
A. Explain implied consent to the client’s family.
B. Contact the facility social work to obtain the consent.
C. Request that the client’s guardian sign the consent
D. Ask the charge nurse to obtain informed consent.
Client who has been judged incompetent has a temporary or permanent guardian appointed by the court. The guardian can sign the informed consent for the client.
..................................................................................................................................................................................................................CONTINUE. [Show Less]
