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 D

Explanation

A. Telling the client that the voices they are hearing are not real may invalidate their experience and could increase their distress or resistance to the nurse's intervention.
B. While discussing strategies for the next occurrence might be helpful, it does not address the immediate situation or acknowledge the client's current experience.
C. Asking the client to focus on something else may be perceived as dismissive and may not effectively engage them in conversation or provide support.
D. Acknowledging that the client appears to be speaking with someone validates their experience without confirming the reality of the voices. This comment encourages the client to express themselves and provides an opening for further communication, allowing the nurse to assess the situation more effectively.

A. A summary of the client’s feelings B. The client’s significant other’s statement C. A general description D. Photographs

Correct Answer is D

Explanation

A. Documenting the client’s feelings is important but may not provide objective evidence of injuries.
B. The significant other’s statement may be biased and may not accurately represent the client's injuries.
C. A general description may lack specificity, making it difficult to convey the extent and nature of the injuries.
D. Photographs are objective and provide visual documentation of the injuries, offering a clear and accurate record for legal and healthcare purposes.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes a client with a history of psychosis repeatedly looking to the side and mumbling responses to no one present in that direction. Which comment is best for the nurse to make?

Correct Answer is D

Explanation

The nurse completes an assessment of a client experiencing intimate partner violence (IPV). Which finding of the injuries should the nurse include in the documentation?

Correct Answer is D

Explanation

When assessing a client who takes psychotropic medications, the nurse notes that the client has uncontrollable hand movements and is excessively protruding the tongue. Which assessment in the client’s record should the nurse review?

A male client with schizophrenia continues to talk to others on the mental health unit using tangential speech. What intervention should the nurse implement?

A client who is an alcoholic receives a prescription for disulfiram 500 mg PO daily. Which instruction should the nurse provide to this client?

A client who refuses antipsychotic medications disrupts group activities, talks with nonsensical words, and wanders into client’s rooms. The nurse decides that the client needs constant observation based on which of these assessment findings?

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?

The nurse is leading a group on the inpatient psychiatric unit. Which approach should the nurse use during the working phase of group development?

An older man with a history of multiple falls at home tells the clinic nurse that his son, who was incarcerated last year for assault and battery, has become increasingly abusive since his release from prison six weeks ago. Which intervention is most important for the nurse to implement?