A nurse at an urgent care center is caring for a client who sustained minor injuries during a street fight in which two of the client's friends were stabbing victims. The client tells the nurse that he doesn't remember anything that happened after he and his friends first saw the suspects in the stabbing. Which of the following defense mechanisms is the client demonstrating?

Projection

Dissociation

Repression

Sublimation

Answer and Explanation

The Correct Answer is B

Dissociation is a defense mechanism in which a person disconnects from their thoughts, feelings, memories, or sense of identity as a way to cope with overwhelming or traumatic experiences. In this case, the client's inability to remember anything that happened after seeing the suspects in the stabbing is a form of dissociation. It is a way for the client to psychologically distance themselves from the traumatic event and protect themselves from the emotional distress associated with it.

A- Projection is a defense mechanism where an individual attributes their own undesirable thoughts, feelings, or impulses onto someone else.

C- Repression is a defense mechanism where disturbing or unacceptable thoughts, memories, or feelings are pushed into the unconscious mind.

D- Sublimation is a defense mechanism where unacceptable impulses or emotions are redirected into socially acceptable activities.

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Correct Answer is D

Explanation

This response reflects the therapeutic communication technique of reflection and validation. By acknowledging the client's feelings and reflecting on them back, the nurse shows empathy and encourages further discussion. It allows the client to express their emotions and concerns, fostering a trusting and supportive relationship between the nurse and the client.

incorrect:

A. "You are in really good shape for your age." This response dismisses the client's expressed feelings of despair and does not address the underlying emotions. It fails to acknowledge the client's emotional state and may minimize their concerns.

B. "This is just a minor setback. You will be back on your feet in no time." While the intention may be to provide reassurance, this response invalidates the client's feelings of hopelessness and disregards the significance of their emotional experience. It does not address the client's statement of feeling that their time is up.

C. "The doctors are going to take good care of you. There is nothing to worry about." This response focuses solely on the medical aspect of care and may disregard the client's emotional and existential concerns. It fails to acknowledge the client's expressed feelings of their time being up and does not encourage further exploration of their emotions.

A. Get the client ready for sleep at the same time each night. B. Move the client to a room next to the open nurses' station. C. Encourage client to take a 1-hr nap each afternoon. D. Play the client's favorite music in the room while the client is sleeping.

Correct Answer is A

Explanation

Establishing a consistent bedtime routine and sleep schedule can promote better sleep hygiene and help regulate the client's sleep-wake cycle. By getting the client ready for sleep at the same time each night, the nurse helps create a predictable and calming routine that signals to the body that it is time to sleep.

Incorrect:

B. Move the client to a room next to the open nurses' station: This measure may increase noise and disturbances, which can further disrupt the client's sleep. Providing a quiet and peaceful environment is generally more conducive to restful sleep.

C. Encourage the client to take a 1-hour nap each afternoon: While short daytime naps can be beneficial for some individuals, they may interfere with the client's ability to fall asleep or stay asleep at night. It is generally recommended to limit daytime napping, especially if the client is having trouble sleeping at night.

D. Play the client's favorite music in the room while the client is sleeping: While some individuals find soothing music helpful for relaxation and sleep, it is essential to consider the client's preferences. Not everyone finds music helpful for sleep, and it is important to respect the client's preferences and individual needs. Some clients may find silence or white noise more conducive to sleep.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for an older adult client who has a fractured hip. The client says, "I guess I've lived long enough and my time is up." Which of the following responses should the nurse make?

Correct Answer is D

Explanation

A nurse in a long-term care facility is caring for an older adult client who is anxious and has trouble sleeping at night. Which of the following nursing measures should the nurse implement?

Correct Answer is A

Explanation

A nurse is preparing to change the dressing on the lower leg of an older adult client who is in a wheelchair, and has a history of maladaptive coping skills. The client begins swearing at and verbally abusing the nurse. Which of the following actions should the nurse take?

A nurse is reinforcing teaching with a client who is scheduled to receive electroconvulsive therapy (ECT). Which of the following statements should the nurse include in the teaching?

A nurse on an inpatient mental health unit is caring for a group of clients. Which of the following actions by the nurse demonstrates the ethical concept of autonomy?

A nurse is assisting in the admission process for a client who has a history of violent behavior. The client stands up and begins clenching her fists and arguing with the nurse. Which of the following actions is the priority?

A nurse is caring for an older adult client who has dementia and is agitated. The client says, "I have to go home and see my mother." The nurse replies, "You miss your mother." Which of the following therapeutic techniques is the nurse using?

A nurse is caring for a newly admitted female client who has depression and refuses to get out of bed, dress, or participate in group therapy. Which of the following is an appropriate nursing response?

The nurse is caring for a client who has been admitted Involuntarily for psychiatric treatment. Which of the following Information about involuntary commitment should the nurse provide the client's family?

A nurse is planning an Interview for a newly admitted client and plans to Include the client's family members. Which of the following methods should the nurse use to determine who to include in the interview?