A nurse in an acute care mental health unit is speaking with a client who reports that other clients leave trash in the lounge. Which of the following actions should the nurse take?

Call housekeeping to clean up the lounge.

Promise the client that the issue will be discussed at the next community meeting.

Help the client clean up the dayroom.

Encourage the client to discuss the problem with other clients.

Answer and Explanation

The Correct Answer is D

Answer: (D) Encourage the client to discuss the problem with other clients

Rationale:

A) Call housekeeping to clean up the lounge: While involving housekeeping might address the immediate issue, it does not empower the client or involve them in the community aspect of the unit. The goal in a mental health setting is to encourage clients to take an active role in resolving communal issues, fostering responsibility, and promoting interpersonal communication.

B) Promise the client that the issue will be discussed at the next community meeting: While addressing the issue in a community meeting is appropriate, simply promising to bring it up without involving the client may not address the immediate concern or empower the client to take an active role. The client might feel dismissed if their concerns are not immediately acknowledged or acted upon.

C) Help the client clean up the dayroom: Assisting the client in cleaning the lounge may resolve the mess temporarily but does not address the underlying issue of other clients leaving trash. It is more beneficial for the client to engage in communication with their peers to foster a sense of community and mutual respect.

D) Encourage the client to discuss the problem with other clients: Encouraging the client to communicate directly with their peers is a therapeutic approach that fosters assertiveness and problem-solving skills. It allows the client to express their concerns and take responsibility for addressing issues within the community, which is beneficial in their mental health recovery process.

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Correct Answer is C

Explanation

This response acknowledges the client's expressed desire not to talk and respects their boundaries. It shows support and presence by offering companionship without pressuring the client to discuss their feelings. The nurse's willingness to sit with the client demonstrates empathy and provides a sense of comfort and reassurance.
The other options are not as appropriate:

1. "It might help you feel better if you talk about it." This response disregards the client's stated preference not to talk and may create a sense of pressure or intrusiveness. It is important to respect the client's autonomy and readiness to share their feelings.
2. "Why are you feeling so down?" This response directly asks the client to explain their feelings, which they have already indicated they do not want to discuss. It can be seen as intrusive and may make the client feel uncomfortable or defensive.
3. "I understand. I've felt like that before, too." While empathy is important, this response brings the focus back to the nurse's own experiences, potentially diverting the attention from the client. It is important for the nurse to remain focused on the client's needs and create a supportive environment for them to express their feelings if they choose to do so.

A. Projection B. Dissociation C. Repression D. Sublimation

Correct Answer is B

Explanation

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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A nurse in an acute care mental health unit is speaking with a client who reports that other clients leave trash in the lounge. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse observes that a client is sitting alone in her room crying. As the nurse approaches, she states, "I'm feeling really down and don't want to talk to anyone right now." Which of the following responses is appropriate for the nurse?

Correct Answer is C

Explanation

Correct Answer is B

Explanation

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