A nurse is caring for a client who has a new diagnosis of metastatic lung cancer. The client states, "I can't think about that until after my first grandchild is born next week." The nurse should identify the client's statement as indicating the maladaptive use of which of the following defense mechanisms?

Compensation

Sublimation

Regression

Suppression

Answer and Explanation

The Correct Answer is D

A.   Compensation involves overachieving in one area to make up for deficiencies in another area, which is not evident in the client's statement.
B.   Sublimation involves channeling unacceptable impulses into socially acceptable activities, which is not demonstrated in the client's statement.
C.   Regression involves reverting to an earlier stage of development in the face of stress, which is not evident in the client's statement.
D.   Suppression involves consciously avoiding or postponing dealing with a stressor, which aligns with the client's statement of delaying thinking about their diagnosis until after a significant event.

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Correct Answer is B

Explanation

A. Discussing the importance of confidentiality is important but should not be the first action.
Addressing immediate emotional needs and coping strategies takes precedence.

B. Identifying prior coping skills helps establish a foundation for managing the current crisis. It allows the nurse to build on existing strengths and provide support tailored to the adolescents'
individual needs.

C. Reviewing community resources is valuable but should come after addressing immediate emotional needs and identifying coping skills.
D. Initiating referrals may be necessary, but it should follow the identification of coping skills and immediate emotional support.

A. The client demonstrates that he is oriented to person, place, and time. B. The client states that he will harm himself unless the restraints are removed. C. The client is able to follow commands. D. The client refuses to take his medication unless he is released.

Correct Answer is C

Explanation

A. Orientation to person, place, and time is important for assessing mental status but may not necessarily indicate the need for restraint removal.
B. Self-harm threats should be taken seriously but may require further assessment and intervention rather than immediate restraint removal.
C. The ability to follow commands indicates a level of cooperation and self-control, which may warrant removal of restraints as the client can potentially be managed without them.
D. Refusal to take medication may necessitate further intervention but may not directly indicate the need for restraint removal unless it poses an immediate risk to the client's safety.

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Naxlex Comprehensive Predictor Exams

A nurse is leading a crisis intervention group for adolescents who witnessed the suicide of a classmate. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

A nurse is caring for a client who has physical restraints applied. The nurse determines that the restraints should be removed when which of the following occurs?

Correct Answer is C

Explanation

A nurse is caring for a client who has bulimia nervosa. Which of the following interventions should the nurse include in the client's plan of care?

A nurse is teaching a client who is to start taking fluoxetine. The nurse should instruct the client that which of the following supplements Interacts adversely with fluoxetine?

A nurse is caring for a client who has an anxiety disorder and is scheduled for a procedure. The client informs the nurse that they do not want to have the procedure. Which of the following actions should the nurse take?

A nurse is caring for a client who has antisocial personality disorder and reports planning to hurt their partner upon discharge. Which of the following actions should the nurse take?

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A nurse in an acute care facility is planning care for a client who has a history of alcohol use disorder and is admitted while intoxicated. Which of the following interventions should the nurse plan for the client?