A nurse in an acute care mental health facility is creating a plan of care for a newly admitted client. Which of the following interventions should the nurse plan to include in the working phase of the nurse-client relationship?

Summarize the objectives the client achieved during the relationship.

Present issues regarding confidentiality.

Promote the client's problem-solving skills.

identify the responsibilities of the client and nurse.

Answer and Explanation

The Correct Answer is C

A. Summarize the objectives the client achieved during the relationship:
This intervention is more appropriate for the termination phase of the nurse-client relationship. During termination, the nurse summarizes the progress made, goals achieved, and skills learned during the therapeutic relationship. This helps both the nurse and the client reflect on the journey and celebrate accomplishments.

B. Present issues regarding confidentiality:
Discussing confidentiality is crucial and typically occurs in the orientation phase of the nurse-client relationship. Establishing trust and clarifying the boundaries of confidentiality early in the relationship helps the client feel secure and promotes open communication. This choice is relevant during the initial stages of the therapeutic relationship.

C. Promote the client's problem-solving skills:
This is the correct choice for the working phase of the nurse-client relationship. In this phase, the focus is on active problem-solving, exploring feelings and thoughts, and encouraging the client to develop coping strategies. The nurse supports the client in identifying problems, generating solutions, and implementing effective strategies. Promoting the client's problem-solving skills is a central aspect of therapeutic work during this phase.

D. Identify the responsibilities of the client and nurse:
Clarifying the responsibilities of both the client and nurse is essential to establish clear roles and expectations. This usually occurs in the orientation phase. During this phase, the nurse explains the purpose of the therapeutic relationship, the roles of both parties and the boundaries of the nurse-client interaction. Establishing clear responsibilities helps create a foundation for a respectful and effective therapeutic alliance.

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Correct Answer is B

Explanation

A. Rambling speech
Rambling speech is not a typical finding associated with depression. It may indicate other conditions or issues.

B. Insomnia
Insomnia, or difficulty sleeping, is a common symptom of depression. Many individuals with depression experience trouble falling asleep, staying asleep, or both.

C. Rapid mood swings
Rapid mood swings are not typically associated with depression. Depression often involves persistent low mood rather than rapid fluctuations.

D. Sundowning
Sundowning refers to a state of confusion and restlessness that occurs in the late afternoon and evening, often seen in individuals with dementia. While it can be related to mood disturbances, it's not specific to depression.

A. Reaction formation B. Suppression C. identification D. Compensation

Correct Answer is C

Explanation

A. Reaction Formation:
Reaction formation is a defense mechanism where an individual expresses feelings or behaviors that are the opposite of their true feelings or impulses. For example, someone who harbors unconscious aggressive feelings might display exaggerated friendliness and kindness. In the given scenario, the behavior of the newly licensed nurse is not contradictory to their true feelings; they are imitating the charge nurse willingly.

B. Suppression:
Suppression is a conscious effort to push down or hide certain thoughts or feelings. Unlike repression (which is unconscious), suppression involves a deliberate choice not to think about or dwell on certain emotions or thoughts. In the scenario, the behavior of the newly licensed nurse is not an example of suppression because they are not consciously trying to hide their actions.

C. Identification:
Identification is a defense mechanism where an individual unconsciously models their behavior, feelings, or attitudes after those of someone else, especially someone they perceive as powerful or significant. In this scenario, the newly licensed nurse is imitating the behaviors of the charge nurse, which is an example of identification.

D. Compensation:
Compensation is a defense mechanism where an individual consciously or unconsciously covers up weaknesses, frustrations, or feelings of inadequacy by emphasizing strengths or seeking to excel in other areas. It involves making up for a perceived lack by putting extra effort into another aspect of life. The scenario does not describe the newly licensed nurse compensating for any perceived weakness; they are simply imitating the charge nurse's behavior.

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A nurse in an acute care mental health facility is creating a plan of care for a newly admitted client. Which of the following interventions should the nurse plan to include in the working phase of the nurse-client relationship?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility is assessing an older adult client for depression. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A charge nurse is orienting a newly licensed nurse and observes the newly licensed nurse imitating her behaviors. The nurse should recognize this behavior as which of the following defense mechanisms?

Correct Answer is C

Explanation

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