A nurse is caring for a client who has bipolar disorder. The client says to the nurse, “Give me your pen to cut the pain out of my chest.” The nurse should identify that the client is at risk for which of the following?

Illusion

Hallucination

Attention-seeking behavior

Self-mutilation

Answer and Explanation

The Correct Answer is D

Choice A reason:
An illusion is a misinterpretation of a real external stimulus. For example, seeing a shadow and thinking it is a person. The client’s statement does not indicate a misinterpretation of reality but rather a desire to inflict harm on themselves.
Choice B reason:
A hallucination is a false sensory perception without any real external stimulus, such as hearing voices or seeing things that are not there. The client’s statement does not suggest they are experiencing a hallucination but rather expressing a desire to self-harm.
Choice C reason:
Attention-seeking behavior involves actions taken to gain attention from others. While the client’s statement could be seen as a cry for help, it is more accurately identified as a risk for self-mutilation due to the explicit mention of wanting to cut themselves.
Choice D reason:
Self-mutilation refers to deliberate self-inflicted harm, often as a way to cope with emotional pain. The client’s statement, “Give me your pen to cut the pain out of my chest,” clearly indicates a risk for self-mutilation, as they are expressing a desire to harm themselves to alleviate emotional distress.

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Correct Answer is ["A","C","D"]

Explanation

Choice A reason:
An electroencephalogram (EEG) monitor is essential for monitoring the brain’s electrical activity during ECT. This equipment helps ensure that the treatment is administered safely and effectively by providing real-time data on the patient’s brain waves. The EEG monitor is crucial for assessing the patient’s response to the therapy and detecting any abnormalities.
Choice B reason:
An ophthalmoscope is used to examine the interior structures of the eyes, which is not relevant to the ECT procedure. Therefore, it is not necessary to set up an ophthalmoscope in the room prior to ECT. The focus of ECT preparation is on monitoring the patient’s neurological and cardiovascular status, not on eye examinations.
Choice C reason:
A cardiac monitor is vital for tracking the patient’s heart rate and rhythm during ECT. This equipment helps detect any cardiac abnormalities or arrhythmias that may occur as a result of the treatment. Continuous cardiac monitoring ensures that any potential complications can be promptly addressed, making it an essential piece of equipment for ECT.
Choice D reason:
A blood pressure monitor is necessary for measuring the patient’s blood pressure before, during, and after the ECT procedure. Monitoring blood pressure is crucial for detecting any significant changes that could indicate cardiovascular stress or other complications. This equipment helps ensure the patient’s safety throughout the treatment.
Choice E reason:
A portable X-ray machine is not required for ECT. X-rays are used for imaging purposes, which are not part of the standard ECT procedure. The primary focus during ECT is on monitoring the patient’s neurological and cardiovascular status, making the portable X-ray machine unnecessary for this context.

A. PROJECTION B. DENIAL C. DISPLACEMENT D. PASSIVE-AGGRESSION

Correct Answer is C

Explanation

Choice A reason:
Projection involves attributing one’s own unacceptable thoughts or feelings to others. This is not the correct answer because the man’s behavior of punching walls and yelling at his significant other is an outward expression of his own frustration, rather than projecting his feelings onto someone else. Projection would involve accusing others of having the feelings or thoughts that he himself is experiencing.
Choice B reason:
Denial is a defense mechanism where an individual refuses to accept reality or facts, blocking external events from awareness. This is not the correct answer because the man’s actions indicate that he is reacting to his frustration rather than denying its existence. Denial would involve ignoring or refusing to acknowledge the feelings or situation that is causing distress.
Choice C reason:
Displacement is the redirection of emotions or impulses from a threatening target to a safer one. This is the correct answer because the man redirects his anger from his supervisor, who is the source of his frustration, to a less threatening target, which is his significant other and the walls at home. Displacement allows the individual to express their emotions in a way that feels safer or more acceptable.
Choice D reason:
Passive-aggression involves expressing negative feelings indirectly rather than openly addressing them. This is not the correct answer because the man’s behavior is direct and aggressive, rather than passive. Passive-aggressive actions might include sulking, procrastination, or subtle resistance, none of which are evident in the described scenario.

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A nurse is caring for a client who has bipolar disorder. The client says to the nurse, “Give me your pen to cut the pain out of my chest.” The nurse should identify that the client is at risk for which of the following?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to assist with electroconvulsive therapy (ECT). Which of the following pieces of equipment should the nurse set up in the room prior to the treatment? (Select all that apply)

Correct Answer is ["A","C","D"]

Explanation

After being scolded by his supervisor at work, a man comes home and punches several holes in his walls and yells at his significant other. Which of the following defense mechanisms does this scenario depict?

Correct Answer is C

Explanation

When providing care to a client diagnosed with a mental disorder, the client asks the nurse, “Does mental illness run in your family?” Which response by the nurse would be nontherapeutic?

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When applying the biopsychosocial model to a client with a mental health problem, the nurse addresses which psychological domain?

When communicating with a client, which would a nurse use to convey positive body language?

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