A nurse is discussing mental health with a client. Which of the following statements by the client requires follow-up by the nurse?
"My boss often asks me to work overtime, but I have to refuse the extra hours due to my responsibilities at home."
"The demands of raising two young children by myself are often overwhelming, and I sometimes need some alone time to recharge."
"On the weekends when my kids are with their other parent, I often just lay in bed all day and cry, because I feel hopeless."
"Work can be extremely stressful at times, so I often need to take a walk during my lunch break."
The Correct Answer is C
Rationale:
A. This statement reflects a healthy boundary-setting behavior, where the client recognizes their limits and makes decisions accordingly.
B. This reflects a healthy coping mechanism, where the client acknowledges their stress and takes time to recharge, which is important for mental health.
C. This statement indicates a possible depressive symptom, as feeling hopeless and withdrawing from activities (like staying in bed and crying) can be signs of depression. This requires follow-up to assess the client's mental health and provide appropriate support.
D. Taking a walk during stressful times is a positive coping strategy that helps manage stress and maintain mental health.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Denial involves refusing to accept reality but is not as characteristic of borderline personality disorder as splitting.
B. Reaction formation involves behaving in a manner opposite to one's true feelings, which is not the primary defense mechanism in borderline personality disorder.
C. Splitting is a common defense mechanism in borderline personality disorder where the client views people or situations as all good or all bad, potentially causing conflict within the healthcare team.
D. Regression involves reverting to earlier developmental stages but does not typically cause division among healthcare providers.
Correct Answer is B
Explanation
Rationale:
A. Pill rolling movements and drooling are more characteristic of Parkinson’s disease rather than serotonin syndrome.
B. Serotonin syndrome can present with autonomic instability such as dilated pupils, hyperthermia, and loss of muscle coordination due to increased serotonin levels.
C. Tinnitus is not a common symptom of serotonin syndrome; jerking movements may occur but are not specific to this condition.
D. Suicidal ideations are not typical of serotonin syndrome; they may be more related to underlying mood disorders or medication effects.
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