The mother of an 8-month-old infant with profound mental and physical disabilities tells the nurse how depressed she is because she realizes that her child will never achieve normal growth and development milestones. How should the nurse respond to this mother?

Encourage the mother to write thoughts and feelings in a journal.

Determine if the mother has other children who do not have developmental disabilities.

Reassure the mother that her child will achieve some growth and development milestones.

Ask the mother if she has ever thought about harming herself or her child.

Answer and Explanation

The Correct Answer is A

Choice A rationale:
Encouraging the mother to write her thoughts and feelings in a journal is a constructive and therapeutic response. It provides an outlet for the mother to express her emotions and can be a helpful tool for coping with the challenges she is facing.

Choice B rationale:
Determining if the mother has other children who do not have developmental disabilities may be relevant to understanding her support system and family dynamics, but it does not directly address her current emotional distress.

Choice C rationale:
Reassuring the mother that her child will achieve some growth and development milestones may not be appropriate in this situation, as the child's disabilities are described as profound, and it is uncertain what milestones the child will reach. Providing false hope may not be helpful and could be misleading.

Choice D rationale:
Asking the mother if she has ever thought about harming herself or her child is an important inquiry related to her emotional state and the potential risk of harm. However, it should follow the initial response of encouraging her to express her thoughts and feelings in a journal.

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Correct Answer is A

Explanation

Choice A rationale:
Teaching the client to develop a plan for daily structured activities is a key intervention for addressing major depressive disorder with symptoms like psychomotor retardation, hypersomnia, and motivation. Structured activities can help the client regain a sense of purpose, improve motivation, and gradually return to a normal level of functioning.

Choice B rationale:
Encouraging exercise is generally beneficial for mental health, but it may not be the most effective intervention for addressing the specific symptoms mentioned in this scenario.

Choice C rationale:
Suggesting the client develop a list of pleasurable activities is a valuable intervention but may not directly address the psychomotor retardation and hypersomnia seen in this case.

Choice D rationale:
Providing education on methods to enhance sleep is important, especially if hypersomnia is a symptom, but it should be part of a broader treatment plan that also includes addressing psychomotor retardation and motivation.

A. The client discusses moving to Hawaii instead of returning to rebuild her house. B. The client seems unemotional when talking about needing to rebuild her house. C. The client states that she sometimes forgets why she is in the hospital. D. The client is frightened that the hospital will burn down.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"D"}}

Explanation

A. The client discusses moving to Hawaii instead of returning to rebuild her house.

Defense Mechanism: Fantasy

Explanation: The client may be using fantasy as a way to escape from the painful reality of her situation. Discussing moving to a place like Hawaii, which may represent an idealized and stress-free environment, suggests a desire to avoid confronting the challenges and emotions associated with her current circumstances.

B. The client seems unemotional when talking about needing to rebuild her house.

Defense Mechanism: Isolation

Explanation: Isolation, or emotional isolation, occurs when an individual separates emotions from the events or thoughts associated with them. The client's lack of emotional response when discussing rebuilding her house suggests that she may be isolating her feelings to avoid distress.

C. The client states that she sometimes forgets why she is in the hospital.

Defense Mechanism: Suppression

Explanation: Suppression involves the conscious effort to avoid thinking about distressing thoughts or memories. The client's statement that she sometimes forgets why she is in the hospital may indicate an attempt to suppress or avoid focusing on the traumatic event that led to her hospitalization.

D. The client is frightened that the hospital will burn down.

Defense Mechanism: Denial

Explanation: Denial involves refusing to accept the reality of a situation, which can manifest as irrational fears or beliefs. The client's fear that the hospital will burn down may reflect a form of denial, as she might be projecting her fear of the collapse (a traumatic event) onto another catastrophic event, thereby avoiding dealing with her actual trauma.

Summary of Answers:

A. Fantasy - The client discusses moving to Hawaii instead of returning to rebuild her house.
B. Isolation - The client seems unemotional when talking about needing to rebuild her house.
C. Suppression - The client states that she sometimes forgets why she is in the hospital.
D. Denial - The client is frightened that the hospital will burn down.

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The mother of an 8-month-old infant with profound mental and physical disabilities tells the nurse how depressed she is because she realizes that her child will never achieve normal growth and development milestones. How should the nurse respond to this mother?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A middle-aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and motivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning?

Correct Answer is A

Explanation

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"D"}}

Explanation

A. The client discusses moving to Hawaii instead of returning to rebuild her house.

B. The client seems unemotional when talking about needing to rebuild her house.

C. The client states that she sometimes forgets why she is in the hospital.

D. The client is frightened that the hospital will burn down.

During a routine assessment at an outpatient clinic, the nurse notes that a client has abdominal obesity and a high waist-hip ratio, with a body mass index of 32 kg/m2. Which action(s) should the nurse take in response to these findings? (Select all that apply.)

Patient Data Exhibits The client has been in IMU unit for 3 days and the physician plans to discharge her home today. Select the client actions that were effective in her treatment.

A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?

A female client with bulimia is admitted to the mental health unit after she disclosed to a friend that she purges after meals. Which intervention should the nurse implement first?

A client with depression does not want to communicate with friends, uses television watching as a means of escaping responsibilities, and describes the inability to handle personal circumstances. Which coping strategy should the nurse include in the plan of care?

A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. Which action should the nurse implement?

A preschool-aged girl tells the school nurse that her hair hurts. The nurse finds that the child's hair has been arranged to cover several small bald spots. Which finding indicates to the nurse that the hair loss is not disease-related?