The client has used defensive communicating with the nurse today. Which can be a positive outcome from the use of defense mechanisms?

Defense mechanisms can create difficulty with relationships

Defense mechanisms can lead to poor problem-solving skills

Defense mechanisms can help a person to reduce anxiety

Defense mechanisms can inhibit emotional growth

Answer and Explanation

The Correct Answer is C

Choice A reason: Defense mechanisms, like denial or projection, can strain relationships by avoiding honest communication or projecting blame, disrupting trust and emotional connection. While they may temporarily reduce anxiety, they hinder interpersonal dynamics, making this a negative outcome rather than a positive one in therapeutic interactions.

Choice B reason: Defense mechanisms can impair problem-solving by avoiding reality (e.g., denial) or displacing emotions, preventing rational analysis of issues. This leads to maladaptive coping, which does not address underlying problems, making it a negative consequence rather than a positive outcome of using defense mechanisms in mental health contexts.

Choice C reason: Defense mechanisms, such as repression or rationalization, temporarily reduce anxiety by shielding the individual from overwhelming emotions or stressors. By mitigating psychological distress, they provide short-term emotional relief, allowing the person to function under stress, making this a positive outcome when used adaptively in mental health management.

Choice D reason: Defense mechanisms can inhibit emotional growth by preventing individuals from confronting and processing emotions, leading to unresolved issues. Overreliance on mechanisms like avoidance stalls emotional development, hindering self-awareness and coping skills, making this a negative outcome rather than a positive benefit of defense mechanisms.

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Correct Answer is D

Explanation

Choice A reason: Saying “I am not sure I follow you” seeks clarification, encouraging the patient to elaborate without dismissing their feelings. It fosters open communication, allowing the nurse to understand the patient’s concerns better, which supports therapeutic interaction and validates the patient’s emotional expression in a clinical setting.

Choice B reason: Noticing lip-biting acknowledges nonverbal cues, signaling the nurse’s attentiveness to the patient’s emotional state. This observation invites further discussion without judgment, promoting trust and validating the patient’s feelings, which is therapeutic and does not undermine or belittle their concerns in a mental health context.

Choice C reason: Stating “You appear tense” reflects observation of the patient’s emotional state, prompting exploration of underlying issues. It validates the patient’s feelings without dismissal, encouraging dialogue. This therapeutic approach supports emotional expression and does not belittle concerns, making it appropriate in a nurse-patient interaction.

Choice D reason: Saying “Everything will be alright” dismisses the patient’s concerns by offering false reassurance without addressing specific issues. This minimizes their emotional experience, potentially invalidating feelings and discouraging open communication, which can undermine trust and hinder therapeutic progress in managing mental health concerns.

A. A client who states they intend to harm self and others B. A client who has diabetes who refuses to follow the prescribed diet C. A client who is unable to control rage and is assaulting others D. A client who does not bathe regularly or change clothes often

Correct Answer is A

Explanation

Choice A reason: Stating intent to harm self and others meets criteria for involuntary hospitalization (e.g., 302 commitment), as it indicates imminent danger. Mental health laws prioritize safety, requiring inpatient evaluation to prevent suicide or violence, making this client eligible for involuntary admission to stabilize their condition.

Choice B reason: Refusing a diabetic diet is nonadherence but does not meet criteria for involuntary mental health hospitalization, which requires mental health-related danger to self or others. This behavior may warrant medical intervention, but it lacks the psychiatric urgency needed for involuntary admission.

Choice C reason: Uncontrolled rage with assaultive behavior indicates imminent danger to others, meeting criteria for involuntary hospitalization. Mental health laws allow commitment to protect others and stabilize the client, as assault reflects a severe mental health crisis requiring inpatient intervention to prevent further harm.

Choice D reason: Poor hygiene does not constitute imminent danger to self or others, a requirement for involuntary hospitalization. While it may indicate mental health issues, it lacks the acute risk needed for commitment, making outpatient evaluation or support more appropriate than involuntary admission.

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The client has used defensive communicating with the nurse today. Which can be a positive outcome from the use of defense mechanisms?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which statement by a nurse may undermine a patient’s feelings and belittle the patient’s concerns?

Correct Answer is D

Explanation

The nurse is evaluating clients in the emergency department (ED) for pending mental health admissions. Which client will be admitted for involuntary hospitalization?

Correct Answer is A

Explanation

An adult client was put in restraints after all other attempts to reduce aggression have failed. Which is required now that restraints have been instituted by the nurse?

Which of the following would the nurse expect to find when reviewing the laboratory test results of a client with renal failure?

The client has used defensive communicating with the nurse today. Which can be a positive outcome from the use of defense mechanisms?

A nurse is talking with a patient, and 5 minutes remain in the session. The patient has been silent for most of the session. Another patient comes to the door of the room, interrupts, and says, “I really need to talk to you right now.” The nurse should:

A nurse is assigned to administer oral medications to a client. Which action will the nurse do first if a client refuses to take prescribed oral medications?

A nurse is performing safety assessments on a client in mechanical restraints as required by policy. Which action by the nurse demonstrates the ethical principle of nonmaleficence?

A novice nurse is beginning work on a behavioral health unit and states to the preceptor, “What if I encounter a client who is sexually aggressive?” Which is the appropriate response by the preceptor?

A nurse assesses a confused older adult. The nurse experiences sadness and reflects, “The patient is like one of my grandparents… so helpless.” What feelings does the nurse describe?