A hospitalized client is told that he has terminal cancer. The client adamantly believes that the physician is wrong despite biopsy results and MRI findings. This is an example of which of the following?

Anger

Anxiety

Withdrawal

Denial

Answer and Explanation

The Correct Answer is D

D. Denial is a defense mechanism where individuals refuse to acknowledge or accept a painful or distressing reality. In this case, despite objective medical evidence (biopsy results and MRI findings), the client persists in believing that the diagnosis of terminal cancer is incorrect. This refusal to accept the reality of the situation is characteristic of denial.

A. Anger typically involves feelings of frustration, resentment, or hostility towards others or the situation. While anger can be a reaction to receiving a terminal diagnosis, it is not reflective of refusing to accept the diagnosis itself.

B. Anxiety involves feelings of worry, fear, or unease about future events or uncertainties. While anxiety can accompany a terminal diagnosis, it does not manifest as outright refusal or disbelief in the diagnosis itself.

C. Withdrawal refers to a retreat or disengagement from social interactions or activities. It can be a coping mechanism in response to stress or difficult emotions. However, withdrawal does not specifically relate to refusing to accept a diagnosis like terminal cancer.

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Correct Answer is B

Explanation

B. This is the most appropriate initial action. One-to-one observation ensures constant monitoring of the client's safety and prevents further harm, such as another suicide attempt or self-harm. Given the client's history of depression and recent suicide attempt, ensuring their safety is paramount.

A. This option is not the first priority because while addressing anorexia nervosa is important, safety concerns related to the suicide attempt and potential substance abuse take precedence. Making a weight gain contract requires the client's cooperation and readiness, which may not be feasible immediately upon admission.

C. While assessing the severity of depression is crucial, it is secondary to ensuring immediate safety in this context. The client's safety must be established first through continuous observation and intervention.

D. While important to understand the substances involved in the suicide attempt, this action is secondary to ensuring ongoing safety through direct observation. Toxicology results can guide subsequent treatment decisions but are not as urgent as immediate safety measures.

A. Give the client two aspirin tablets and monitor his headache and heart rate B. Notify the physician immediately C. Notify the physician when convenient D. Reassure the client that these are common side effects of his medication

Correct Answer is B

Explanation

B. This is the correct priority action. Serotonin syndrome can be life-threatening if not promptly recognized and treated. The physician needs to be notified immediately so that appropriate actions can be taken to manage the client's symptoms and potentially adjust the medication regimen.

A. Aspirin is not appropriate for treating serotonin syndrome. Monitoring the client's symptoms is important, but this action does not address the potential seriousness of the symptoms described.

C. Delaying notification could lead to worsening of symptoms and potential complications. Given the potential seriousness of serotonin syndrome, waiting until it's convenient is not appropriate.

D. While headache, palpitations, and stiffness could potentially be side effects of antidepressant medication, the combination of these symptoms raises concern for serotonin syndrome, which requires immediate medical attention rather than reassurance alone.

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A hospitalized client is told that he has terminal cancer. The client adamantly believes that the physician is wrong despite biopsy results and MRI findings. This is an example of which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the admission of a client to an acute mental health unit following a suicide attempt. The client has a history of depression, substance abuse, and anorexia nervosa. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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