A nurse in an urgent care facility is caring for a client who has traumatic injuries following an assault. The client sits quietly and calmly tells the nurse, "I'm fine." The nurse should recognize the client's behavior as which of the following reactions?

Projection

Displacement

Denial

Undoing

Answer and Explanation

The Correct Answer is C

The client's behavior of stating "I'm fine" despite having traumatic injuries is an example of denial, a coping mechanism that involves denying that a problem or issue exists. Projection involves attributing one's own feelings to another person, displacement involves redirecting one's emotions onto a less threatening target, and undoing involves seeking to undo or forget past actions.

Choice A, projection, would involve the client attributing their own feelings to others.

Choice B, displacement, would involve the client redirecting their emotions onto someone or something else. Finally,

choice D, undoing, would involve the client attempting to forget or undo past actions.

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Correct Answer is ["B","D","E"]

Explanation

The client with OCD may experience difficulty relaxing and often feels tense, anxious, and irritable. They may engage in rule-conscious behavior and exhibit perfectionist tendencies, as well as experience compulsive behaviors. These behaviors may be time-consuming and interfere with daily activities.

Option A is incorrect because irrational fear of certain objects is more indicative of a phobia than OCD.

Option C is incorrect because clients with OCD are usually aware of their compulsions and may even try to resist them.

Reasons why the other options are not correct answers:

Option A: Irrational fear of certain objects is more indicative of a phobia than OCD.

Option C: Clients with OCD are usually aware of their compulsions and may even try to resist them.

A. Initiate one-to-one nursing observation. B. Make a contract with the client for weight gain. C. Administer the Hamilton depression scale. D. Review the client's toxicology laboratory report.

Correct Answer is A

Explanation

initiate one-to-one nursing observation, as this is the most urgent intervention to ensure the safety of the client. The client has a history of depression, substance abuse, anorexia nervosa, and attempted suicide, which indicates that they are at high risk for harm to themselves. One-to-one observation involves an assigned staff member who will be with the client at all times, ensuring their safety and preventing any further self-harm attempts.

Choice B, making a contract with the client for weight gain, is not an appropriate first action as it does not address the client's immediate safety concerns.

Choice C, administering the Hamilton depression scale, may be important to assess the client's depressive symptoms but is not the most urgent priority.

Choice D, reviewing the client's toxicology laboratory report, may be necessary for the overall assessment of the client, but safety comes first.

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A nurse in an urgent care facility is caring for a client who has traumatic injuries following an assault. The client sits quietly and calmly tells the nurse, "I'm fine." The nurse should recognize the client's behavior as which of the following reactions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is collecting data from a client with obsessive-compulsive disorder (OCD). Which of the following findings should the nurse expect? (Select all that apply.)

Correct Answer is ["B","D","E"]

Explanation

A nurse is assisting with the admission of a client to an acute mental health unit following a suicide attempt. The client has a history of depression, substance abuse, and anorexia nervosa. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is collecting data from a client who has obsessive-compulsive disorder (OCD) and finds that the client demonstrates constant repetitive cleaning. The nurse should realize that the client's repetitive behaviors occur due to which of the following?

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