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?

Stop the car in the client's driveway and call the authorities.

Honk the car horn to get the client's attention.

Calmly speak the client's name out of the car window.

Keep driving in a path that is going away from the client's house.

Answer and Explanation

The Correct Answer is D

Choice A reason:

Stop the car in the client’s driveway and call the authorities. This statement is wrong because stopping in the driveway could escalate the situation and put the nurse in immediate danger. The nurse should avoid any actions that might provoke the client or put herself in harm’s way.

Choice B reason:

Honk the car horn to get the client’s attention. This statement is wrong because honking the horn could startle the client, potentially leading to a violent reaction. Sudden loud noises can exacerbate agitation in individuals with schizophrenia.

Choice C reason:

Calmly speak the client’s name out of the car window. This statement is wrong because engaging with the client directly while they are armed is unsafe and could provoke aggression. The nurse should avoid direct interaction until the situation is secured.

Choice D reason:

Keep driving in a path that is going away from the client’s house. This is the correct action as it ensures the nurse’s safety by distancing herself from the potentially dangerous situation. Once at a safe distance, the nurse can contact the authorities for assistance.

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Correct Answer is C

Explanation

Choice A Reason:
Universality refers to the realization among group members that they are not alone in their experiences or feelings. While the interaction does show a shared experience, the primary factor demonstrated here is not just the commonality of experience but the encouragement and hope it provides.

Choice B Reason:
Imitative Behavior involves group members learning from each other by observing and copying behaviors. In this scenario, while the member who has been sober for 7 years may serve as a role model, the key element in this interaction is the hope conveyed through sharing personal success.

Choice C Reason:
Instillation of Hope is the encouragement that recovery is possible. The member's statement about overcoming multiple relapses and achieving long-term sobriety serves as a powerful testament to the possibility of recovery, thus instilling hope in others.

Choice D Reason:
Altruism is the unselfish concern for the welfare of others, which can be a byproduct of group therapy as members support each other. However, the primary factor at play in this scenario is the provision of hope rather than the act of giving support.

A. Conversion B. Regression C. Projection D. Undoing E. Disliking a neighbor is not a condition that warrants an extended hospital hold. Personal feelings or disputes do not equate to a risk that justifies involuntary hospitalization.

Correct Answer is C

Explanation

Choice A reason:
Conversion is a defense mechanism where emotional distress is expressed through physical symptoms. This does not apply to the student's behavior, which is verbally directed towards the teacher and the course rather than manifesting as physical symptoms.

Choice B reason:
Regression involves reverting to behaviors typical of an earlier developmental stage when faced with stress. The student's behavior does not indicate a regression to childlike behaviors but rather an outward projection of feelings onto the teacher and course.
Choice C reason:
Projection is a defense mechanism where an individual attributes their own unacceptable thoughts, feelings, or motives to another person. In this case, the student is projecting their feelings of failure and frustration onto the teacher and course, blaming them for the negative outcome.

Choice D reason:
Undoing is a defense mechanism where a person tries to 'undo' an unhealthy, destructive, or otherwise threatening thought or action by engaging in contrary behavior. The student's action of berating does not attempt to undo the failure but instead shifts responsibility away from themselves.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse at a college campus mental health counseling center is caring for a student who just failed an examination. The student spends the session berating the teacher and the course. The nurse should recognize this behavior as which of the following defense mechanisms?

Correct Answer is C

Explanation

The nurse is caring for a client diagnosed with catatonia. Which of the following should be a priority action by the nurse?

A nurse in a psychiatric unit is admitting a client who attacked a neighbor. The nurse should know that the client can be kept in the hospital after the 72-hour hold is over for which of the following conditions?

A nurse is developing a care plan for a newly admitted client who has schizophrenia and experiences frequent hallucinations and paranoid delusions. Which of the following actions should the nurse plan to take?

A nurse is assessing a client who is receiving treatment with multiple antipsychotic medications and who suddenly became ill. The findings include blood pressure changes, fever, and diaphoresis. The nurse should recognize that which of the following adverse effects may be occurring?

A nurse is discussing therapeutic milieu with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of therapeutic milieu?

A nurse is reviewing communication styles. Which of the following characteristics should the nurse identify as being exhibited by an aggressive communicator? (Select All that Apply.)

A nurse is caring for a client diagnosed with severe manifestations of schizophrenia and is prescribed haloperidol (Haldol) PRN for agitation. The nurse should recognize which of the following as adverse effects of haloperidol (Haldol)?