A client is admitted to a psychiatric unit for treatment of a psychotic disorder. The client is at the locked exit door and is shouting. "Let me out! There's nothing wrong with me! I don't belong here!" The nurse identifies this behavior as which defense mechanism?

Denial

Regression

Projection

Rationalization

Answer and Explanation

The Correct Answer is A

A.   This is the defense mechanism where a person refuses to acknowledge a painful reality. In this case, the client is denying their illness and the need for hospitalization.
B.   This involves reverting to childlike behaviors as a way to cope with stress. It doesn't fit the scenario.
C.   This is attributing one's own unacceptable thoughts or feelings onto others. There's no evidence of this in the given situation.
D.   This involves creating excuses to justify unacceptable behavior. The client is not justifying their behavior but denying it.

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Correct Answer is ["A","C","E"]

Explanation

A. Providing companionship can help reduce feelings of isolation and agitation that may be exacerbated by sundown syndrome. Presence and interaction with a supportive person can provide comfort, reassurance, and a sense of security, which may help manage anxiety and agitation during the late hours.
B. Engaging in stimulating activities in the late afternoon or evening can sometimes worsen symptoms of sundown syndrome. Instead, activities should be calming and relaxing as excessive stimulation can
increase agitation and confusion. It’s better to plan stimulating activities earlier in the day.
C. Maintaining a familiar routine helps provide structure and predictability, which can be comforting for individuals with dementia. Consistent routines can help reduce confusion and anxiety, especially during the times when sundown syndrome symptoms are most pronounced.
D. While reminding the client about bedtime may seem like a good strategy, it can sometimes lead to frustration or increased agitation if the client is not ready for sleep or is confused. It is generally more effective to create a calming environment and use soothing routines rather than directly reminding the client of bedtime.
E. Reducing environmental stimulation, such as minimizing noise, bright lights, and other distractions, can help create a calm and peaceful environment. This approach can help prevent overstimulation, which is known to exacerbate sundown syndrome symptoms.

A. Confidentiality B. Autonomy C. Beneficence D. Nonmaleficence

Correct Answer is B

Explanation

A. This principle relates to protecting patient information. It is not relevant to this scenario.
B. This principle respects the patient's right to self-determination. By disregarding the client's preference for walking with her daughter, the nursing assistant violated the client's autonomy.
C. This principle involves doing good for the patient. While the nursing assistant might have intended to benefit the client by encouraging exercise, it was done at the expense of the client's autonomy.
D. This principle involves avoiding harm to the patient. While the client was upset, there is no evidence of physical harm in this situation.

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A client is admitted to a psychiatric unit for treatment of a psychotic disorder. The client is at the locked exit door and is shouting. "Let me out! There's nothing wrong with me! I don't belong here!" The nurse identifies this behavior as which defense mechanism?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which interventions will help to lessen the effects of sundown syndrome? (Select al that apply)

Correct Answer is ["A","C","E"]

Explanation

Correct Answer is B

Explanation

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