A nurse is conducting an admission interview with a new client who tells the nurse, "My life is so stressful. I can't take it anymore." Which of the following responses should the nurse make first?

"How have you dealt with stress in the past?"

"Are you thinking of harming yourself?"

"Let's talk more about what you are experiencing."

"Tell me what makes you feel stressed."

Answer and Explanation

The Correct Answer is B

The nurse should make safety a priority and assess the client's risk for suicide first, before exploring other aspects of the client's stress level. The client's statement indicates hopelessness and despair, which are warning signs of suicidal ideation.

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Correct Answer is D

Explanation

Rationalization is a defense mechanism that involves making excuses or justifying one's behavior or failures. The client who blames their boss for not getting a promotion is using rationalization to avoid accepting responsibility or acknowledging their shortcomings. The other examples are not related to rationalization, but to other defense mechanisms, such as somatization, denial, and procrastination.

A. Refusing to participate in group activities B. Talking negatively about other staff members C. Expressing frustration regarding unit rules D. Reacting to the nurse as though she were his mother

Correct Answer is D

Explanation

Transference is a defense mechanism in which the client unconsciously transfers feelings, attitudes, or impulses from a past relationship to a current one, such as a health care provider. The nurse should recognize this behavior and maintain professional boundaries with the client. The other options are not specific to transference and may indicate other issues.

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A nurse is conducting an admission interview with a new client who tells the nurse, "My life is so stressful. I can't take it anymore." Which of the following responses should the nurse make first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse is educating a newly licensed nurse about various defense mechanisms. Which of the following examples should the charge nurse provide when discussing rationalization?

Correct Answer is D

Explanation

A nurse is caring for a client who has a personality disorder and is using transference to cope. Which of the following behaviors should the nurse expect?

Correct Answer is D

Explanation

A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanisms is the client demonstrating?

A nurse is providing teaching to a client who is prescribed methylphenidate for ADHD. Which of the following statements by the client indicates accurate understanding of this medication's effects?

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A nurse is developing a behavioral contract with a client who has antisocial personality disorder. Which of the following client goals should the nurse include in the contract?

A charge nurse is making room assignments for new client admissions. Which of the following clients should the nurse place closest to the nurse's station?

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