A nurse in an acute care mental health facility is sitting with a client who has schizophrenia.

The client whispers to the nurse, “I’m being kept in this prison against my will.

Please try to get me out.” Which of the following responses should the nurse make?

“We are here to help you and give you the care that you need right now.”

“You feel that you don’t belong here?”

“Why do you feel that you need to leave?”

“Try to take some deep breaths and I’m sure you’ll feel better.”

Answer and Explanation

The Correct Answer is B

Choice A:

While this response is well-intentioned, it may not be the most therapeutic in this situation. It could be perceived as dismissive of the client's feelings and concerns. Clients with schizophrenia often have difficulty trusting others, and this response could reinforce the client's belief that they are being held against their will.

It's important to acknowledge the client's feelings and concerns, rather than simply stating that the healthcare team is there to help.

Choice B:

This response is the most therapeutic because it uses the technique of reflection. Reflection involves echoing back the client's feelings or thoughts, which can help them feel heard and understood. It can also encourage the client to elaborate on their concerns.

By reflecting the client's statement, the nurse validates their feelings and opens the door for further communication.

Choice C:

This response could be perceived as confrontational or challenging, which could further escalate the client's anxiety. It's generally more helpful to start with a more open-ended question or reflection.

Asking "why" questions can sometimes make people feel defensive or put on the spot.

Choice D:

While relaxation techniques can be helpful for some clients, this response is not appropriate in this situation. It minimizes the client's concerns and does not address their underlying feelings of fear and anxiety.

It's important to validate the client's feelings before suggesting coping strategies.

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Correct Answer is B

Explanation

Choice A rationale:

Hemoglobin (Hgb) of 11 g/dL is slightly below the normal range for adult females (12-16 g/dL) but is not considered a critical value.

It may indicate mild anemia, which is common in bulimia nervosa due to factors such as poor nutrition and blood loss from self-induced vomiting. However, it would not typically be the most urgent finding requiring immediate intervention.

Choice B rationale:

Potassium of 2.8 mEq/L is significantly below the normal range (3.5-5.0 mEq/L) and is considered a critical value, indicating severe hypokalemia.

Hypokalemia is a potentially life-threatening electrolyte imbalance that can lead to cardiac arrhythmias, muscle weakness, respiratory failure, and even death.

It is a common complication of bulimia nervosa due to excessive vomiting and/or laxative abuse, which can lead to significant potassium loss.

Therefore, this finding would be the nurse's priority, necessitating immediate intervention to correct the hypokalemia and prevent potentially life-threatening complications.

Choice C rationale:

Serum chloride of 96 mEq/L is slightly below the normal range (98-106 mEq/L) but is not considered a critical value.

It may be associated with hypokalemia, as chloride and potassium are often lost together in conditions like bulimia nervosa.

However, it would not typically be the most urgent finding requiring immediate intervention.

Choice D rationale:

Serum amylase of 240 units/L is elevated above the normal range (30-110 units/L) but is not considered a critical value.

It may indicate inflammation of the pancreas (pancreatitis), which can be a complication of bulimia nervosa due to recurrent vomiting and/or alcohol abuse.

However, it would not typically be the most urgent finding requiring immediate intervention, especially in comparison to severe hypokalemia.

A. “I mentally separate myself from distractions around me when I paint on canvas.” B. “I wrote a short story about a heroic woman when I was really mad at my boss.” C. “I still cannot remember the scene of my husband’s car accident.” D. “I don’t care about work anymore since I was not given a promotion.”

Correct Answer is D

Explanation

Choice A rationale:

Mental separation from distractions during painting is a healthy coping mechanism, allowing for focus and mindfulness.

It falls under the adaptive defense mechanism of compartmentalization, which involves temporarily separating thoughts and emotions to manage stress effectively.

It doesn't deny or distort reality, but rather creates a temporary mental space for relaxation and creativity.

Choice B rationale:

Writing a short story about a heroic woman is a form of sublimation, channeling negative emotions into a productive and creative outlet.

It's a mature defense mechanism that allows for indirect expression of anger or frustration without causing harm to oneself or others.

It can lead to personal growth and insight, as it encourages reflection and exploration of emotions through storytelling.

Choice C rationale:

Inability to recall the scene of a traumatic event is likely a dissociative defense mechanism, protecting the individual from overwhelming psychological distress.

It's a common response to trauma, and while it may be maladaptive in the long term if it prevents processing the trauma, it serves a protective function in the acute phase.

It doesn't necessarily indicate a maladaptive coping style overall, but rather a specific response to a traumatic experience.

Choice D rationale:

Declaring disinterest in work after being denied a promotion exemplifies disengagement, a maladaptive coping mechanism involving withdrawal and apathy.

It reflects an inability to cope with disappointment or setbacks in a constructive way.

It can lead to social isolation, decreased motivation, and potentially depression or other mental health issues.

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A nurse in an acute care mental health facility is sitting with a client who has schizophrenia. The client whispers to the nurse, “I’m being kept in this prison against my will. Please try to get me out.” Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the admission laboratory values for a client who has a history of bulimia nervosa. Which of the following findings is the nurse’s priority?

Correct Answer is B

Explanation

During a group therapy session, a nurse observes several clients using multiple defense mechanisms. Which of the following client statements demonstrates the use of maladaptive coping mechanisms?

Correct Answer is D

Explanation

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A nurse in an acute care mental health facility is caring for a client who begins to yell and scream at staff members. Which of the following actions is the nurse’s priority?

A nurse in an acute care mental health facility is sitting with a client who has schizophrenia.

The client whispers to the nurse, “I’m being kept in this prison against my will.

Please try to get me out.” Which of the following responses should the nurse make?