A nurse is assisting in the care of a client whose partner has end-stage lung cancer. The client states, "The doctors say he only has a few months to live, but I know that with treatment he will get better." The nurse should identify that the client is exhibiting which of the following defense mechanisms?

Splitting

Denial

Displacement

Repression

Answer and Explanation

The Correct Answer is B

A. Splitting : Splitting is a defense mechanism where a person sees others as all good or all bad, which is not evident in this scenario.

B. Denial: Denial is refusing to accept reality as a way to cope with distress. The client rejects the prognosis and insists on recovery despite medical evidence.

C. Displacement : Displacement is shifting emotions onto a less threatening target (e.g., being angry at a nurse instead of at the bad news).

D. Repression : Repression is unconsciously blocking out distressing thoughts rather than actively rejecting the reality of a loved one’s condition.

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Correct Answer is C

Explanation

A. Resolution phase: The resolution phase is the final phase when the client gradually takes control of their care and prepares for discharge.

B. Identification phase: The identification phase is when the client identifies problems and begins to develop a sense of belonging with the nurse.

C. Orientation phase. The orientation phase is when the nurse collects data, assesses knowledge, establishes trust, and collaborates with the client to develop mutual goals.

D. Exploitation phase : The exploitation phase (working phase) is when the client actively engages in treatment and utilizes available resources.

A. The nurse describes what happened by providing general and broad details. B. The nurse includes the client's own words when describing what happened. C. The nurse describes what happened subjectively. D. The nurse includes the opinions of other team members.

Correct Answer is B

Explanation

A. The nurse describes what happened by providing general and broad details. Incident reports should be factual, objective, and specific, not general or vague.

B. The nurse includes the client's own words when describing what happened. Including direct quotes from the client ensures accuracy and avoids interpretation or bias.

C. The nurse describes what happened subjectively. Incident reports must be objective, avoiding personal opinions or assumptions.

D. The nurse includes the opinions of other team members. Only document observable facts and direct quotes—opinions should not be included.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What phase of the therapeutic involves the nurse collects data, assesses knowledge, and works with the patient to develop mutual goals?

Correct Answer is C

Explanation

A nurse on a mental health unit is preparing to document an incident that occurred involving a client. Which of the following considerations by the nurse will ensure competency in the documentation?

Correct Answer is B

Explanation

A nurse is assisting in the care of a client who states, "I am overwhelmed by stress, and nobody is helping me." Which of the following represents a therapeutic response by the nurse?

A nurse is discussing therapeutic milieu with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates and understanding of therapeutic milieu?

A nurse in a mental health unit is discussing restraints and seclusion with a group of newly hired nurses. At which of the following times should a nurse discuss the restraint and seclusion policy with a client?

Which of the following describes a team of mental health LPNs and RNs who work together to provide client care?

Which of the following is a strategy to reduce nursing burnout?

A nurse is discussing the scope of practice and responsibilities of mental health nurses who are not advanced practice registered nurses with a peer. Which of the following responsibilities is within the nurse's scope of practice?

A nurse is caring for a client who states, "Whenever I have to give a presentation at my job, my vision goes really blurry and my feet go numb." Which of the following defense mechanisms is the client describing?

A nurse is interviewing a client who states, "I am at a total loss and don't know what to do anymore. I feel hopeless." Which of the following responses should the nurse make?