A nurse at a mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is using dissociation as a defense mechanism?

A client forgets to buy their partner a birthday gift after a disagreement.

A client who was abused as a child describes the abuse as if it happened to someone else.

A client who is shorter than average is verbally assertive with coworkers.

A client states that they did not get a job promotion because the boss did not like them.

Answer and Explanation

The Correct Answer is B

- A. This choice is incorrect because forgetting to buy a gift is not an example of dissociation, but rather a sign of poor memory or lack of attention.

- B. This choice is correct because describing the abuse as if it happened to someone else is an example of dissociation, which is a defense mechanism that involves separating oneself from painful or traumatic experiences.

- C. This choice is incorrect because being verbally assertive is not an example of dissociation, but rather a personality trait or a coping skill.

- D. This choice is incorrect because blaming the boss for not getting a promotion is not an example of dissociation, but rather a sign of external locus of control or rationalization.

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Correct Answer is B

Explanation

A. Incorrect. Withholding pain medications for 24 hr after the old patch is removed is a harmful action that could cause severe withdrawal symptoms and uncontrolled pain for the client. The nurse should respect the client's right to refuse treatment and explore the reasons for their decision.
B. Correct. Asking another nurse to witness the disposal of the new patch is a safe and legal action that follows the policies and procedures for handling controlled substances. The nurse should document the disposal of the new patch and report it to the appropriate authority.
C. Incorrect. Sealing the patches in a plastic bag and placing them in the client's trash basket is an unsafe and illegal action that could lead to diversion, misuse, or accidental exposure of fentanyl to others. The nurse should dispose of the patches in a secure and designated container that prevents access by unauthorized persons.
D. Incorrect. Sticking the two patches to each other and placing them in the sharps bin is an unsafe and improper action that could cause contamination, injury, or infection to others who handle or dispose of sharps waste. The nurse should dispose of the patches separately and carefully, avoiding contact with their adhesive surfaces.

A. "I'm sure your family does not want you to die." B. "Why would you believe such things?" C. "How does this make you feel?" D. "You should talk to your family about your feelings."

Correct Answer is C

Explanation

How does this make you feel?

A. Saying "I'm sure your family does not want you to die" is not a therapeutic response, as it invalidates the client's feelings and imposes the nurse's assumption on the client. This option is incorrect.
B. Asking "Why would you believe such things?" is not a therapeutic response, as it sounds judgmental and confrontational, and may make the client feel defensive or ashamed. This option is incorrect.
C. Asking "How does this make you feel?" is a therapeutic response, as it encourages the client to express their emotions and shows empathy and interest from the nurse. This option is correct.
D. Saying "You should talk to your family about your feelings" is not a therapeutic response, as it implies that the client is responsible for resolving their family issues and may increase their guilt or anxiety. This option is incorrect.

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A nurse at a mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is using dissociation as a defense mechanism?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to replace a client's transdermal fentanyl patch after 72 hr of use. After the nurse opens the packet containing the new pouch, the client declines to accept it. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is admitting a client to the psychiatric unit after attempting suicide. The client states, "My family does not care whether I live or die." Which of the following responses should the nurse make?

Correct Answer is C

Explanation

A nurse is teaching about how to suppress lactation with a client who is postpartum and bottle-feeding her newborn. Which of the following instructions should the nurse include in the teaching?

A nurse is planning to administer packed RBCs to an older adult client who has a low hemoglobin level.Which of the following actions should the nurse plan to take?

While a nurse is caring for a client who is receiving mechanical ventilation via an endotracheal tube, the high-pressure alarm on the ventilator sounds.Which of the following actions should the nurse take?

A nurse is caring for a client who has signed an informed consent form to receive electroconvulsive therapy (ECT). The client states to the nurse, "I'm not sure about this now. I'm afraid it's too risky." Which of the following responses should the nurse make?

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A nurse is preparing to administer a blood transfusion to a client. Which of the following procedures should the nurse follow to ensure proper client identification?

A nurse on an inpatient mental health unit is monitoring a visit between a client who has a history of aggressive behavior and the client's partner. Which of the following observations should the nurse identify as an indication for potential violence?