During a one-to-one session with the nurse, a female client admitted for chronic depression and attempted suicide discloses experiences of sexual promiscuity and prostitution. When the nurse asks the client if she was ever sexually abused as a child, the client says, “I don’t remember, but my mother ran my father off when I was five.” The nurse should recognize that the client may be using which defense mechanism?

Regression.

Projection.

Denial.

Repression.

Answer and Explanation

The Correct Answer is D

A.   Regression involves reverting to an earlier stage of development in response to stress, which is not evident in the client's response.
B.   Projection involves attributing one's thoughts or feelings to another person, which is not evident in the client's response.
C. Denial involves refusing to acknowledge the existence of something unpleasant, which is not evident in the client's response.
D.   Repression involves unconsciously blocking out memories or feelings, and the client's statement of not remembering past sexual abuse may indicate the use of repression as a defense mechanism.

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Correct Answer is A

Explanation

A. The client's statements about having an IQ of 400+, being married to a movie star, and suspecting his brother's intentions may indicate a distorted perception of reality, suggesting disturbed sensory perception. This priority addresses the potential psychosis and immediate safety concerns.
B. Compromised family coping, while important, is a secondary consideration. Addressing the client's altered sensory perception takes precedence to ensure their safety and
stabilization.
C. Ineffective sexual patterns are not as immediate concerns as the potential distorted sensory perception. Ensuring the client's mental stability is the primary goal upon admission to the psychiatric unit.
D. Impaired environmental interpretation is not as immediate concerns as the potential distorted sensory perception. Ensuring the client's mental stability is the primary goal upon admission to the psychiatric unit.

A. Reinforce personal strengths observed in the client. B. Suggest ways to problem solve adapting to the new home. C. Help the client know they will not always feel this way. D. Inquire respectfully about the events of the departure.

Correct Answer is D

Explanation

A. Reinforcing personal strengths is a positive intervention, but in this context, understanding the underlying cause of anxiety should take precedence.
B. Suggesting ways to problem-solve adapting to the new home is a valuable intervention, but assessing the specific stressors or traumas the client may have experienced is more immediate.
C. Helping the client know they will not always feel this way is supportive, but understanding the context and potential triggers for anxiety is the first step.
D. Inquiring respectfully about the events of the departure is the most important initial intervention to gather information about potential traumatic experiences that may be contributing to the client's anxiety.

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Naxlex Comprehensive Predictor Exams

A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?

Correct Answer is A

Explanation

The nurse is caring for a client who is a refugee from another country and who is experiencing daily episodes of anxiety. The client communicates minimally with the nurse, looking away and appearing distressed. Which intervention is most important for the nurse to do first?

Correct Answer is D

Explanation

The nurse is preparing medications for a client with bipolar disorder and notices that the antipsychotic medication was discontinued several days ago. Which medication should also be discontinued?

A client who is experiencing a severe level of anxiety reports a racing heartbeat, dizziness, and expresses a sense that something dreadful will happen. The nurse observes the client pacing and waving hands rapidly. Which action should the nurse take?

A client at the mental health center reports difficulty concentrating at work, feeling very tired during the day, and sleeping 4 to 5 hours at night. To further assess for depression, which question is most important for the nurse to ask?

While visiting the community mental health center, a client with a diagnosis of major depressive disorder asks the nurse if what is shared with the staff will be shared with family members. How should the nurse respond to this client?

A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit’s day room. Which action should the nurse implement first?

The nurse is teaching a group of adolescents about assertive communication. Two of the adolescents are seated at a round table and another is sitting on a small sofa nearby. To facilitate group interaction, which intervention is best for the nurse to implement?