A nurse caring for a client is preparing to access the client’s implanted medication port (Medi port). The client states, “Every time I have to have my port accessed, I get extremely anxious, and I have heart palpitations.” Which response by the nurse would be most appropriate for the assessment stage of crisis intervention?

“Let's talk to the doctor about getting something ordered before the procedure."

“That must be overwhelming considering how often we access the port."

"Do you think you will be able to control your anxiety in the future?'

“What have you done in the past to relieve or reduce your anxiety during the procedure?"

Answer and Explanation

The Correct Answer is D

This response by the nurse would be most appropriate for the assessment stage of crisis intervention because it focuses on understanding the client’s past experiences and coping mechanisms. By asking the client about what has worked for them in the past, the nurse can help the client identify and use eﬀective strategies to manage their anxiety during the procedure.

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Correct Answer is A

Explanation

During the orientation phase of the nurse-client relationship, the nurse and client get to know each other and establish rapport. This involves building trust and establishing a connection between the nurse and the client. The nurse will also explain their role and the purpose of the relationship and set goals and expectations for the relationship.

A. Disassociation-adaptive B. Denial-adaptive C. Rationalization-maladaptive D. Altruism-maladaptive

Correct Answer is A

Explanation

Disassociation is a defense mechanism that involves mentally separating oneself from a stressful or traumatic situation in order to maintain a sense of calm and focus. In this scenario, the nurse is able to block out the sirens and alarms, which may be causing stress and anxiety, and maintain a calm and focused demeanor while speaking with the client's family. This is an adaptive use of disassociation because it allows the nurse to provide eﬀective care and support to the family despite the chaotic environment.

Denial is a defense mechanism that involves denying or minimizing the existence of a stressful or traumatic situation. Rationalization involves justifying or excusing one's behavior or actions. Altruism involves selﬂessly helping others as a way of dealing with one's own problems. In this scenario, none of these defense mechanisms are being used by the nurse.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During the orientation phase of the nurse-client relationship, which of the following will occur?

Correct Answer is A

Explanation

A nurse is speaking to the family of a Trauma victim. The nurse is blocking out the siren and alarm noises while speaking with the client’s family. They ask,” How can you be so calm and focused with all this noise going on?” The nurse is practicing which defense mechanism?

Correct Answer is A

Explanation

The primary reason a client should be included in their treatment plan, if possible, would be for which of the following purposes?

A nurse is admitting a client to the psychiatrist unit after attacking a neighbor. The nurse should know that the client can be kept in the hospital after the 72 hours hold is over when which of the following conditions is met?

While awaiting the biopsy report, the client reports being afraid of a diagnosis of cancer. How should the nurse respond?

A client was involuntarily admitted to a behavioral health facility after trying to harm himself. Which statement by the client would indicate further education is needed regarding his rights?

A nurse is working with a client who used a condescending tone of voice in the conversation. Which response by the nurse is most therapeutic?

Clients are provided opportunities to attend Friday night movie night and tokens for the concession area when they have achieved attending and participating in five focused therapeutic group sessions. The nurse understands this is which form of therapy?

Benjamin Rush included kindness, exercise, and what other method into his care?