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 B

Explanation

A. Sitting in the chair next to the client may be a supportive action but does not address the immediate concern of the client's behavior.
B. Listening to what the client is saying is crucial to understand the content and nature of the auditory hallucinations, which can guide further interventions.
C. Escorting the client to his room may be necessary if the behavior poses a risk, but understanding the content of the hallucinations should precede immediate removal.
D. Administering a PRN sedative may be considered later based on the assessment, but understanding the nature of the hallucinations and the client's current state is the priority.

A. Assess intake and output. B. Monitor for wheezing and apnea. C. Limit visitors to family members only. D. Assign the client to a teen support group.

Correct Answer is B

Explanation

A. Assessing intake and output is important for overall monitoring but does not address the specific concerns related to heroin detoxification.
B. Monitoring for wheezing and apnea is crucial during the first 24 hours after admission for heroin detoxification to ensure respiratory stability.
C. Limiting visitors is a general precaution but may not be the most important intervention related to the physiological effects of heroin detoxification.
D. Assigning the client to a teen support group is a valuable intervention for overall support but may not address the immediate physiological concerns of heroin detoxification.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

An adolescent who is a heroin addict is admitted to the unit for detoxification. What intervention is most important for the nurse to initiate during the first 24 hours after admission?

Correct Answer is B

Explanation

An adolescent female with an eating disorder is admitted to the in-patient psychiatric unit. Which intervention should the nurse implement?

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

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?

A client with paranoia is admitted to the mental health unit and immediately goes to the corner of the room and sits quietly without communicating. In approaching the client, what intervention should the nurse implement first?

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?