A nurse is caring for an adolescent on an inpatient mental health unit who is undergoing detoxification for a substance use disorder. He tells the nurse that he first began using illicit drugs when his parents wouldn't allow him to get a tattoo. Which of the following defense mechanisms is the client demonstrating?

Suppression

Intellectualization

Dissociation

Projection

Answer and Explanation

The Correct Answer is D

Projection is a defense mechanism where an individual attributes their own thoughts, feelings, or impulses onto someone else. In this case, the client is attributing the cause of their drug use to their parents not allowing them to get a tattoo. By projecting their desire for a tattoo onto their parents' decision, the client is displacing their own feelings onto an external factor.

Incorrect:

A. Suppression: Suppression involves consciously pushing away or blocking unwanted thoughts, feelings, or impulses. The client's statement does not indicate an attempt to suppress any thoughts or emotions related to their drug use; instead, they are openly discussing the reason for their substance use.

B. Intellectualization: Intellectualization involves using excessive reasoning or logic to avoid acknowledging or experiencing associated emotions. The client's statement does not reflect intellectualization, as they are not overly relying on intellectual processes or attempting to detach themselves from the emotional aspects of their behavior.

C. Dissociation: Dissociation involves a temporary disconnection from thoughts, feelings, or memories to avoid emotional distress. The client's statement does not demonstrate dissociation, as they are connecting their drug use to a specific event and cause.

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Correct Answer is A

Explanation

The response "I will assist you in getting out of bed and getting dressed" demonstrates a supportive and therapeutic approach. It acknowledges the client's current state and offers assistance to engage in self-care activities. By providing support and actively participating in the client's care, the nurse can promote motivation, engagement, and a sense of empowerment.

The response "You can remain in bed until you feel well enough to join the milieu" may enable the client's depressive behaviors and reinforce the avoidance of activities. It does not encourage participation or provide support for the client to engage in therapeutic activities.

The response "The unit rules state that clients may not remain in bed" focuses on enforcing rules rather than addressing the client's underlying emotional state and needs. It may increase resistance and hinder the therapeutic relationship.

The response "If you don't participate in your care, you will not get better" may be perceived as blaming or judgmental. It may increase the client's guilt or sense of failure and does not provide practical support or encouragement.

A. "Why do you think the copper helps with your arthritis?" B. "I think you should rely more on your medication therapy than on your bracelet." C. "Yes, I understand that you feel better wearing your bracelet." D. "Believing objects have powers to make you feel better has no scientific basis."

Correct Answer is C

Explanation

This response acknowledges the client's subjective experience and validates their belief that the bracelet provides pain relief. It shows empathy and respect for the client's perspective without dismissing or challenging their belief.

Let's review the other options and explain why they are not the most appropriate responses:

A. "Why do you think the copper helps with your arthritis?" This response may come across as questioning or doubting the client's belief, which can be invalidating and may hinder the

nurse-client relationship.

B. "I think you should rely more on your medication therapy than on your bracelet." While it is important to emphasize evidence-based medical treatments, this response may be perceived as dismissive or confrontational. It is essential to maintain a supportive and collaborative approach.

D. "Believing objects have powers to make you feel better has no scientific basis." Although this statement is true in terms of scientific evidence, it may undermine the client's beliefs and create a sense of defensiveness or disagreement. It is more effective to maintain a respectful and non-judgmental attitude.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a newly admitted female client who has depression and refuses to get out of bed, dress, or participate in group therapy. Which of the following is an appropriate nursing response?

Correct Answer is A

Explanation

A client who has rheumatoid arthritis shows the nurse at her provider's office her magnetic copper bracelet and says that it helps alleviate her pain when she wears it. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

A nurse is caring for a client who has a major depressive disorder. Which of the following actions should the nurse take when developing a relationship with the client?

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A nurse is observing a newly licensed nurse as she assists in providing family therapy for a client regarding relationship concerns with his spouse. Which of the following statements to the client by the newly licensed nurse requires intervention by the nurse?

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A nurse on a mental health unit is participating in a community meeting with a group of clients. Which of the following actions should the nurse take?