A charge nurse is educating a newly licensed nurse about various defense mechanisms. Which of the following examples should the charge nurse provide when discussing rationalization?

A client who has stomach pain before presenting a project to his coworkers.

A client whose partner died 5 years ago still talks about him in the present tense.

A client who states she will worry about her grades after she finishes planning a party.

A client who states she did not get a promotion because her boss dislikes her.

Answer and Explanation

The Correct Answer is D

Rationalization is a defense mechanism that involves making excuses or justifying one's behavior or failures. The client who blames their boss for not getting a promotion is using rationalization to avoid accepting responsibility or acknowledging their shortcomings. The other examples are not related to rationalization, but to other defense mechanisms, such as somatization, denial, and procrastination.

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Correct Answer is ["B","C","D","E"]

Explanation

B is correct because reporting any adverse effects of the medication can help the provider adjust the dosage or prescribe a different medication if needed. Some common adverse effects of haloperidol are extrapyramidal symptoms, tardive dyskinesia, neuroleptic malignant syndrome, and anticholinergic effects.

C is correct because notifying the provider within 48 hr of manifestations of a relapse can help the client receive timely intervention and prevent further deterioration of their mental health. Some signs of a relapse are increased anxiety, paranoia, social withdrawal, insomnia, and mood swings.

D is correct because going for a walk or engaging in other physical activities can help the client cope with stress and reduce anxiety, which are common triggers for schizophrenia symptoms.

E is correct because asking a trusted person to watch for manifestations of illness can help the client gain insight into their condition and seek help when needed. A trusted person can be a family member, a friend, or a mental health professional.

A is incorrect because taking a dose of the medication as soon as delusions or hallucinations begin is not an effective strategy for relapse prevention. The client should take their medication as prescribed by their provider and not adjust the dosage on their own.

F is incorrect because limiting alcohol consumption to no more than two drinks per week is not sufficient for relapse prevention. Alcohol can interact with haloperidol and increase its sedative effects, impairing the client's judgment and cognition. Alcohol can also worsen schizophrenia symptoms and interfere with recovery. The client should avoid alcohol altogether or consult with their provider before consuming any alcohol.

A. A client who has schizotypal personality disorder B. A client who has a history of alcohol use disorder C. A client who has moderate-stage Alzheimer's disease D. A client who has a history of dependent personality disorder

Correct Answer is C

Explanation

A client who has moderate-stage Alzheimer's disease may experience confusion, memory loss, wandering, agitation, and impaired judgment. Placing this client closest to the nurse's station can facilitate close observation and intervention, as well as reduce environmental stimuli that may trigger anxiety or disorientation.

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A charge nurse is educating a newly licensed nurse about various defense mechanisms. Which of the following examples should the charge nurse provide when discussing rationalization?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","C","D","E"]

Explanation

A charge nurse is making room assignments for new client admissions. Which of the following clients should the nurse place closest to the nurse's station?

Correct Answer is C

Explanation

A nurse has placed a client who has become physically aggressive into seclusion. Which of the following actions should the nurse take?

A nurse is reviewing the laboratory report of a client who has a panic disorder and is taking clonazepam. Which of the following laboratory results should the nurse report to the provider?

A nurse in a mental health facility is caring for a client who is being aggressive toward other clients. Which of the following actions is the priority for the nurse to take?

A nurse is planning to conduct a support group for adolescents who have cancer. Which of the following actions should the nurse include during the orientation phase?

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