A nurse in an acute care mental health unit is speaking with a client who reports that other clients leave trash in the lounge. Which of the following actions should the nurse take?

Call housekeeping to clean up the lounge.

Promise the client that the issue will be discussed at the next community meeting.

Help the client clean up the dayroom.

Encourage the client to discuss the problem with other clients.

Answer and Explanation

The Correct Answer is D

Answer: (D) Encourage the client to discuss the problem with other clients

Rationale:

A) Call housekeeping to clean up the lounge: While involving housekeeping might address the immediate issue, it does not empower the client or involve them in the community aspect of the unit. The goal in a mental health setting is to encourage clients to take an active role in resolving communal issues, fostering responsibility, and promoting interpersonal communication.

B) Promise the client that the issue will be discussed at the next community meeting: While addressing the issue in a community meeting is appropriate, simply promising to bring it up without involving the client may not address the immediate concern or empower the client to take an active role. The client might feel dismissed if their concerns are not immediately acknowledged or acted upon.

C) Help the client clean up the dayroom: Assisting the client in cleaning the lounge may resolve the mess temporarily but does not address the underlying issue of other clients leaving trash. It is more beneficial for the client to engage in communication with their peers to foster a sense of community and mutual respect.

D) Encourage the client to discuss the problem with other clients: Encouraging the client to communicate directly with their peers is a therapeutic approach that fosters assertiveness and problem-solving skills. It allows the client to express their concerns and take responsibility for addressing issues within the community, which is beneficial in their mental health recovery process.

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Correct Answer is B

Explanation

Dissociation is a defense mechanism in which a person disconnects from their thoughts, feelings, memories, or sense of identity as a way to cope with overwhelming or traumatic experiences. In this case, the client's inability to remember anything that happened after seeing the suspects in the stabbing is a form of dissociation. It is a way for the client to psychologically distance themselves from the traumatic event and protect themselves from the emotional distress associated with it.

A- Projection is a defense mechanism where an individual attributes their own undesirable thoughts, feelings, or impulses onto someone else.

C- Repression is a defense mechanism where disturbing or unacceptable thoughts, memories, or feelings are pushed into the unconscious mind.

D- Sublimation is a defense mechanism where unacceptable impulses or emotions are redirected into socially acceptable activities.

A. Repression B. Introjection C. Dissociation D. Regression

Correct Answer is D

Explanation

Regression is a defense mechanism that involves reverting to an earlier stage of development or behaving in a way that is characteristic of an earlier developmental level in response to stress or anxiety. It is a way for individuals to cope with overwhelming emotions or situations by retreating to a previous, more comfortable state.

In the scenario described, the client's behavior of consistently being late for appointments and ignoring household chores while expressing the need to be taken care of indicates a regressive response to stress. By relying on others to take care of their responsibilities, the client is seeking a sense of security and support, similar to how they may have relied on others in the past, such as during childhood.

Inc

A- Repression involves the unconscious blocking of unacceptable thoughts or impulses from conscious awareness.

B- Introjection is the internalization of values or qualities of another person or group.

C- Dissociation is a defense mechanism that involves detaching oneself from reality or the present moment to avoid emotional distress.

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A nurse in an acute care mental health unit is speaking with a client who reports that other clients leave trash in the lounge. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Correct Answer is D

Explanation

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