A female client staggers to day treatment smelling strongly of alcohol. She uses the defense mechanism "rationalization" when approached by the nurse and questioned about her recent alcohol consumption. How is this expressed?

"I have not drunk anything in the last day."

"I can't worry about that problem right now."

"I have to drink to relax to come to day treatment."

"Why does it matter to you if I drink?"

Answer and Explanation

The Correct Answer is C

A)   Incorrect. This statement is a straightforward denial rather than rationalization.
B)   Incorrect. This response is an example of avoidance or distraction, not rationalization.
C)   Correct. Rationalization involves offering logical or reasonable explanations to justify behaviors or actions that might otherwise be unacceptable. In this case, the client is rationalizing her alcohol consumption as a means to relax and cope with the day treatment.

D) Incorrect. This statement reflects a defensive response but is not an example of rationalization.

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Correct Answer is A

Explanation

A. Placing the client on one-on-one observation while monitoring for suicidal ideations Given that the client is experiencing auditory hallucinations commanding self harm and is refusing to commit to a safety plan, one-on-one observation is necessary to ensure the client's safety. This

intervention provides constant monitoring and allows for immediate intervention if self harm is attempted.

B. Conducting 15minute checks to ensure safety While conducting regular safety checks is
important, in this case, more continuous monitoring is required due to the severity of the client's symptoms.

C. Encouraging the client to verbalize feelings related to suicide While encouraging communication is essential, in this urgent situation, immediate safety measures take precedence.

D. Completing a room search to ensure there are no harmful objects available to the client
Ensuring the environment is safe is important, but it should be done in conjunction with one-on- one observation to provide the highest level of safety for the client.

A. It prevents withdrawal symptoms. B. It reduces the craving for alcohol. C. It is useful in managing heightened anxiety. D. It treats depressive symptoms.

Correct Answer is B

Explanation

A) Incorrect. Naltrexone does not primarily target withdrawal symptoms. It works by blocking the pleasurable effects of alcohol, reducing the reinforcement that leads to craving.
B) Correct. Naltrexone is an opioid antagonist that reduces the craving for alcohol. It does this by blocking the opioid receptors in the brain, which are involved in the pleasurable effects of
alcohol consumption.
C) Incorrect. Naltrexone is not primarily used to manage anxiety. Its main purpose is to help individuals reduce or stop their alcohol intake.

D) Incorrect. Naltrexone is not primarily used to treat depressive symptoms. Its focus is on reducing alcohol cravings.

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A female client staggers to day treatment smelling strongly of alcohol. She uses the defense mechanism "rationalization" when approached by the nurse and questioned about her recent alcohol consumption. How is this expressed?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client diagnosed with major depressive disorder with psychotic features hears voices commanding self harm. The client refuses to commit to developing a plan for safety. What should be the nurse's priority intervention at this time?

Correct Answer is A

Explanation

A nurse is teaching a group of clients regarding the use of naltrexone in treating alcoholism. What would the nurse teach about the effectiveness of this drug?

Correct Answer is B

Explanation

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