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A nurse is caring for a client who is participating in a therapy session for anger management. The client states that their recent behavior is due to the loss of their job. The nurse should identify that the client is using which of the following defense mechanisms?

Projection

Rationalization

Repression

Sublimation

Answer and Explanation

The Correct Answer is B

b. Rationalization

Explanation:

The correct answer is b. Rationalization.

Rationalization is a defense mechanism characterized by the individual's atempt to justify or explain their behavior or actions in a way that makes it more acceptable to themselves or others. It involves providing logical-sounding reasons or excuses to mask or minimize the real underlying reasons for their behavior.

In this scenario, the client is atributing their recent behavior to the loss of their job, using it as a justification or explanation for their actions. By blaming the job loss, they are rationalizing their behavior as a direct result of the circumstances they faced.

Option a, Projection, involves atributing one's own unacceptable thoughts, feelings, or behaviors to others.

This defense mechanism does not apply to the client's statement about their job loss.

Option c, Repression, involves the unconscious blocking of unwanted thoughts or feelings. It does not relate to the client's behavior or their explanation for it.

Option d, Sublimation, is a defense mechanism where an individual channels or redirects unacceptable impulses or emotions into socially acceptable behaviors or activities. It is not applicable in this context since the client is not expressing their emotions or impulses through alternative constructive means.

By identifying the client's explanation as rationalization, the nurse recognizes the defense mechanism being used and gains insight into how the client is coping with their emotions and justifying their behavior in response to the job loss. This understanding can guide the nurse in providing appropriate support and interventions to help the client manage their anger more eﬀectively.

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Correct Answer is A

Explanation

After the nurse administers a PRN pain medication to a client, the nurse can assign the assistive personnel (AP) to document the client's respiratory rate in 1 hour. This is within the scope of practice of an AP.

The other tasks are not appropriate for an AP to perform.

Monitoring the client for an allergic reactionand evaluating the client for therapeutic eﬀects are both nursing assessments that should be performed by the nurse.

Checking the client's response to the medication is also a nursing assessment that should be performed by the nurse.

A. Derealization B. Illusion C. Hallucination D. Depersonalization

Correct Answer is C

Explanation

c. Hallucination

In the scenario described, the client's experience of receiving special audible messages from the Central Intelligence Agency that no one else can hear indicates a hallucination. Hallucinations are perceptual disturbances in which a person experiences sensory perceptions without any external stimuli. They can occur in any sensory modality, such as hearing (auditory hallucinations), seeing (visual hallucinations), smelling (olfactory hallucinations), tasting (gustatory hallucinations), or feeling (tactile hallucinations).

In this case, the client is experiencing auditory hallucinations, as he is perceiving auditory stimuli (audible messages) that are not present in the external environment. Auditory hallucinations are most commonly associated with schizophrenia, although they can occur in other psychiatric disorders as well.

Derealization (option a) refers to a subjective feeling of unreality or detachment from the environment. It involves a perception that the external world is strange, distorted, or unreal. This is not the primary alteration in perception described in the scenario.

Illusion (option b) is a misinterpretation or misperception of a real sensory stimulus. It occurs when a person's perception of an actual stimulus is distorted or misunderstood. There is no indication of a misperception of a real stimulus in the scenario.

Depersonalization (option d) is a subjective experience of being detached from one's own body, thoughts, or emotions. It involves a feeling of being outside of oneself or observing oneself from a distance. This is not the primary alteration in perception described in the scenario.

Therefore, the correct answer is c. Hallucination, as the client's experience of receiving special audible messages that no one else can hear represents an auditory hallucination.

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A nurse is caring for a client who is participating in a therapy session for anger management. The client states that their recent behavior is due to the loss of their job. The nurse should identify that the client is using which of the following defense mechanisms?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse and assistive personnel (AP) are caring for a client who requests a PRN pain medication. After the nurse administers the medication, which of the following tasks should the nurse assign to the AP?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

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