A nurse overhears a hospitalized client with mania telling another client, "I'm actually a journalist writing an article for a magazine — I'm just
... [Show More] posing as a person with mental illness." How should the nurse respond?
Presenting the client with the actual situation
Rationale: When dealing with a delusional client, it is important for the nurse to state clearly that the nurse does not share the client's perceptions. All three of the other options — ignoring the delusion, taking the client to a quiet room, and supporting the client's denial of illness — do not focus on reality, and they ignore the issue. Presenting the client with the actual situation helps orient the client to reality.
A client who is hallucinating fearfully says to the nurse, "Please tell that demon to get out." How should the nurse respond to the client?
"I know you must be very upset by this, but I don't see a demon."
Rationale: If the client hallucinates, it is best to provide reality-based perceptions and not negate the client's experience, because this may lead to a regressive struggle with the client. Giving advice or false reassurance is incorrect because such techniques indicate that demons actually are present, which feeds into the client's hallucination and reinforces the client's behavior.
The mother of a 3-year-old says, "My child hit his teddy bear after being scolded for picking the neighbors' flowers." Which defense mechanism was the child using?
Displacement
Rationale: The defense mechanism of displacement involves the discharge of intense feelings for one person onto a less threatening substitute person or object to satisfy an impulse. Projection involves attributing an attitude, behavior, or impulse to someone else, such as that which occurs in blaming or scapegoating. Sublimation is rechanneling an impulse into a more socially acceptable object. Identification involves modeling behavior after someone else's.
A client says to the nurse, "Even though my husband and I keep telling them we don't want to have children, our parents are pressuring us to 'start a family.' What should we say to them?" Which of the following responses by the nurse is therapeutic?
"This must be very difficult for both of you."
Rationale: Childless families may elect not to have children or to postpone having them until they have established themselves occupationally or financially. Telling the client to tell the parents that the couple can't have children is incorrect because the client is being encouraged to lie about life decisions rather than helping the parents understand the couple's choices. Asking how they usually cope with such interference is incorrect because it indicates that the nurse is judgmental and has decided that the parents are interfering with the client and spouse. Saying, "Tell them to have more children if they want them so badly," is incorrect because it is sarcastic and ridicules the situation over which the client has expressed concerns.
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