A nurse is assessing a client who has a recent diagnosis of dissociative identity disorder. The client tells the nurse, "I think my blackouts are actually caused by low blood sugar." The nurse should recognize the client is using which of the following defense mechanisms?

Suppression

Sublimation

Projection

Rationalization

Answer and Explanation

The Correct Answer is D

Choice A reason: Suppression is a conscious decision to delay paying attention to an emotion or need in order to cope with the present reality. It's unlikely that the client is consciously choosing to ignore the cause of their blackouts.

Choice B reason: Sublimation is a way of dealing with unacceptable impulses by unconsciously substituting acceptable forms of expression. This defense mechanism doesn't typically apply to explaining symptoms like blackouts.

Choice C reason: Projection involves attributing one's own unacceptable thoughts or feelings to another person. Since the client is providing an explanation for their own symptoms, rather than attributing them to someone else, projection is not the defense mechanism at play here.

Choice D reason: Rationalization involves justifying behaviors or feelings with logical reasons, even if they are not appropriate. The client's attribution of blackouts to low blood sugar, despite a diagnosis that suggests a psychological cause, is a form of rationalization.

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Correct Answer is B

Explanation

Choice A reason: This statement may seem supportive, but it does not address the immediate safety concerns for a client with suicidal ideations and a verbalized plan. Submitting a request for privacy does not mitigate the risk of harm the client may pose to themselves.

Choice B reason: This is the most appropriate response because it directly addresses the safety of the client, which is the primary concern in this situation. It communicates care and concern while also reinforcing the need for observation due to the risk of suicide.

Choice C reason: While safety contracts can be a part of a comprehensive treatment plan, they are not foolproof and should not replace close observation for a client who has expressed suicidal ideations and has a plan. Relying solely on a contract in this situation could be dangerous.

Choice D reason: This statement is factual in that medication levels need to be therapeutic; however, it does not directly address the immediate risk of suicide. Constant observation is required regardless of medication levels if a client has verbalized a plan for suicide.

A. "Have you noticed that your taste has decreased?" B. "Have you noticed an increase in thirst?" C. "Have you noticed unintentional weight loss?" D. "Have you noticed a ringing in your ears?"

Correct Answer is B

Explanation

Choice A reason: Decreased taste is not commonly associated with olanzapine. While some antipsychotic medications can cause changes in sensory experiences, taste reduction is not a typical side effect of olanzapine.

Choice B reason: Increased thirst can be a side effect of olanzapine, as it can cause hyperglycemia, which in turn may lead to polydipsia, or increased thirst. It's important for the nurse to ask about thirst to monitor for potential underlying issues like diabetes.

Choice C reason: Unintentional weight loss is generally not associated with olanzapine. In fact, weight gain is a more common side effect of this medication, so losing weight without trying would be unusual and warrant further investigation.

Choice D reason: Ringing in the ears, or tinnitus, is not a reported side effect of olanzapine. If a patient experiences this symptom, it would likely be related to another condition or medication.

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A nurse is assessing a client who has a recent diagnosis of dissociative identity disorder. The client tells the nurse, "I think my blackouts are actually caused by low blood sugar." The nurse should recognize the client is using which of the following defense mechanisms?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is under observation for suicidal ideations and has verbalized a suicide plan. The client demands privacy and to be left alone. Which of the following statements should the nurse make?

Correct Answer is B

Explanation

A nurse is obtaining a history from a client who has been taking olanzapine to treat schizophrenia. Which of the following questions should the nurse ask the client?

Correct Answer is B

Explanation

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