During a group therapy session, a nurse observes several clients using multiple defense mechanisms.
Which of the following client statements demonstrates the use of maladaptive coping mechanisms?

“I mentally separate myself from distractions around me when I paint on canvas.”

“I wrote a short story about a heroic woman when I was really mad at my boss.”

“I still cannot remember the scene of my husband’s car accident.”

“I don’t care about work anymore since I was not given a promotion.”

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Mental separation from distractions during painting is a healthy coping mechanism, allowing for focus and mindfulness.

It falls under the adaptive defense mechanism of compartmentalization, which involves temporarily separating thoughts and emotions to manage stress effectively.

It doesn't deny or distort reality, but rather creates a temporary mental space for relaxation and creativity.

Choice B rationale:

Writing a short story about a heroic woman is a form of sublimation, channeling negative emotions into a productive and creative outlet.

It's a mature defense mechanism that allows for indirect expression of anger or frustration without causing harm to oneself or others.

It can lead to personal growth and insight, as it encourages reflection and exploration of emotions through storytelling.

Choice C rationale:

Inability to recall the scene of a traumatic event is likely a dissociative defense mechanism, protecting the individual from overwhelming psychological distress.

It's a common response to trauma, and while it may be maladaptive in the long term if it prevents processing the trauma, it serves a protective function in the acute phase.

It doesn't necessarily indicate a maladaptive coping style overall, but rather a specific response to a traumatic experience.

Choice D rationale:

Declaring disinterest in work after being denied a promotion exemplifies disengagement, a maladaptive coping mechanism involving withdrawal and apathy.

It reflects an inability to cope with disappointment or setbacks in a constructive way.

It can lead to social isolation, decreased motivation, and potentially depression or other mental health issues.

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Correct Answer is D

Explanation

Choice D rationale:

Lithium toxicity is a serious and potentially life-threatening condition. It can occur when lithium levels in the blood become too high.

Blurred vision and nausea are common early symptoms of lithium toxicity.

Withholding the medication is the most important action the nurse can take to prevent further toxicity and potential harm to the client.

The nurse should immediately notify the healthcare provider of the client's symptoms and the decision to withhold the medication.

The healthcare provider will likely order a lithium level to be drawn to assess the severity of the toxicity.

Depending on the results of the lithium level, the healthcare provider may order other interventions, such as intravenous fluids or medications to lower the lithium level.

Choice A rationale:

Encouraging the client to rest with his eyes closed may provide some temporary relief from the blurred vision, but it does not address the underlying problem of lithium toxicity.

It is important for the nurse to take more decisive action to prevent further toxicity.

Choice B rationale:

Re-checking the client in 4 hours may delay necessary interventions and allow the lithium toxicity to worsen.

It is important for the nurse to take immediate action to protect the client's health.

Choice C rationale:

Administering the next dose of lithium as prescribed would further increase the lithium level in the blood and could lead to more severe toxicity.

This is not a safe or appropriate action for the nurse to take in this situation.

A. Meaningless phrases B. Refusal to eat C. Substance use D. Decreased energy level

Correct Answer is A

Explanation

Choice A rationale:

Meaningless phrases are a hallmark symptom of schizophrenia and can indicate a worsening of the client's psychosis. This is a significant finding because it suggests that the client's ability to think clearly and communicate effectively is deteriorating.

Prompt reporting to the provider is crucial to ensure timely assessment and intervention, which may include medication adjustments or other therapeutic measures to address the worsening psychosis.

Early intervention is essential to prevent further decline in the client's mental state and to minimize the risk of harm to self or others.

I'll provide detailed rationales for the other choices, even though they are not the priority to report:

Choice B rationale:

Refusal to eat can be a symptom of schizophrenia, but it is not as immediate of a concern as meaningless phrases. It's important to monitor the client's nutritional intake and address any underlying causes of the refusal to eat, but this can typically be managed through nursing interventions without requiring immediate provider notification.

Choice C rationale:

Substance use can exacerbate schizophrenia symptoms and should be addressed, but it is not the priority to report in this scenario. The nurse should assess the client's substance use history and patterns, provide education and counseling on the risks of substance use, and collaborate with the provider to develop a treatment plan that addresses both the schizophrenia and the substance use.

Choice D rationale:

Decreased energy level can be a symptom of schizophrenia, but it is also a common symptom of many other conditions. It's important to assess the client's overall health and identify any potential causes of the decreased energy level, but it is not typically a priority to report to the provider unless it is severe or accompanied by other concerning symptoms

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During a group therapy session, a nurse observes several clients using multiple defense mechanisms. Which of the following client statements demonstrates the use of maladaptive coping mechanisms?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has bipolar disorder and is taking lithium. The client reports blurred vision and nausea. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is caring for a client who has schizophrenia and notices changes in the client’s behavior. Which of the following behaviors is the nurse’s priority to report to the provider?

Correct Answer is A

Explanation

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During a group therapy session, a nurse observes several clients using multiple defense mechanisms.
Which of the following client statements demonstrates the use of maladaptive coping mechanisms?