The Psychiatrist calls Jake’s father to obtain collateral information, pending Jake’s discharge home. Jake’s father reports Jake’s mother died when he was 14 years old. Jake is unable to tell the nurse or Psychiatrist how old he was or the year she died. Which defense mechanism is being depicted?

Regression

Projection

Repression

Suppression

Answer and Explanation

The Correct Answer is C

Choice A reason:
Regression involves reverting to an earlier stage of development in response to stress. This defense mechanism is not indicated by Jake’s inability to recall specific details about his mother’s death.
Choice B reason:
Projection involves attributing one’s own unacceptable thoughts, feelings, or flaws to others. This defense mechanism does not explain Jake’s inability to remember details about his mother’s death.
Choice C reason:
Repression is a defense mechanism where distressing memories, thoughts, or feelings are unconsciously pushed out of conscious awareness. Jake’s inability to recall how old he was or the year his mother died suggests that he may be repressing these painful memories.
Choice D reason:
Suppression is a conscious effort to push distressing thoughts or feelings out of awareness. Since Jake is unable to recall specific details, it is more likely that repression, an unconscious process, is at play.

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Correct Answer is C

Explanation

Choice A reason:

Anticipating removing the restraints every 4 hours is not the best practice. Restraints should be checked frequently, typically every 2 hours, to assess the client’s circulation, skin integrity, and need for continued restraint. The goal is to use restraints for the shortest duration possible.

Choice B reason:

Securing the restraints to the lowest bar of the side rail is incorrect. Restraints should be secured to a part of the bed frame that moves with the client, not to the side rail, to prevent injury and ensure the client’s safety.

Choice C reason:

Securing the restraints using a quick-release tie is the correct action. This ensures that the restraints can be quickly and easily removed in case of an emergency, prioritizing the client’s safety.

Choice D reason:

Ensuring four fingers fit under the restraints to prevent constriction is not accurate. The correct practice is to ensure that two fingers can fit between the restraint and the client’s skin to prevent constriction and ensure proper circulation.

A. Bizarre behavior B. Somatic delusions C. Affective flattening D. Illogicality

Correct Answer is C

Explanation

Choice A reason:
Bizarre behavior is considered a positive symptom of schizophrenia. Positive symptoms are those that add abnormal experiences, such as hallucinations, delusions, and disorganized behavior. Bizarre behavior falls into this category as it represents an addition to normal behavior patterns.
Choice B reason:
Somatic delusions are also positive symptoms of schizophrenia. These delusions involve false beliefs about the body, such as believing one has a serious illness despite medical evidence to the contrary. Positive symptoms are characterized by the presence of abnormal thoughts or behaviors.
Choice C reason:
Affective flattening is a negative symptom of schizophrenia. Negative symptoms are characterized by the absence or reduction of normal functions, such as emotional expression, motivation, and social interaction. Affective flattening refers to a lack of emotional expression, where the individual shows little to no facial expressions or emotional responses.
Choice D reason:
Illogicality, or disorganized thinking, is considered a positive symptom of schizophrenia. It involves incoherent or nonsensical speech and thought patterns. Positive symptoms are those that reflect an excess or distortion of normal functions.

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Naxlex Comprehensive Predictor Exams

A newly licensed nurse is applying prescribed wrist restraints on a client. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is performing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse identify as a negative symptom?

Correct Answer is C

Explanation

A home health nurse drives up to the house of her client, who has schizophrenia with manic episodes. The client is sitting on his front porch with a shotgun in his arms. Which of the following actions should the nurse take?

A nurse is discussing schizophrenia spectrum disorders with a client. The client states, “My friend says that before I started hearing voices, I stopped hanging out with them. Why is that?” Which of the following responses should the nurse make?

A nurse is talking with a client who has schizophrenia. Suddenly the client states, “I’m frightened. Do you hear that? The voices are telling me to do terrible things.” Which of the following responses by the nurse is appropriate?

The nurse calls security and has physical restraints applied to a client who was admitted voluntarily when the client becomes verbally abusive, demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions?

When applying the biopsychosocial model to a client with a mental health problem, the nurse addresses which psychological domain?

A nurse is planning care for a client who has paranoid schizophrenia. Which of the following interventions should be included in the plan of care?

A nurse is caring for a client who is experiencing a crisis related to anxiety. Which of the following actions should the nurse take? (Select all that apply).