A nurse is assessing a client who has a recent diagnosis of dissociative identity disorder. The client tells the nurse, "I think my blackouts are actually caused by low blood sugar." The nurse should recognize the client is using which of the following defense mechanisms?

Suppression

Sublimation

Projection

Rationalization

Answer and Explanation

The Correct Answer is D

Choice A reason: Suppression is a conscious decision to delay paying attention to an emotion or need in order to cope with the present reality. It's unlikely that the client is consciously choosing to ignore the cause of their blackouts.

Choice B reason: Sublimation is a way of dealing with unacceptable impulses by unconsciously substituting acceptable forms of expression. This defense mechanism doesn't typically apply to explaining symptoms like blackouts.

Choice C reason: Projection involves attributing one's own unacceptable thoughts or feelings to another person. Since the client is providing an explanation for their own symptoms, rather than attributing them to someone else, projection is not the defense mechanism at play here.

Choice D reason: Rationalization involves justifying behaviors or feelings with logical reasons, even if they are not appropriate. The client's attribution of blackouts to low blood sugar, despite a diagnosis that suggests a psychological cause, is a form of rationalization.

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Correct Answer is D

Explanation

Choice A reason: Napping during the daytime can interfere with nighttime sleep patterns and is generally not recommended for individuals with insomnia. It can create a cycle of fragmented sleep and may exacerbate difficulties in falling and staying asleep at night.

Choice B reason: While avoiding stimulating activities such as reading in the evening can be helpful for some individuals, it is not a universal recommendation. Reading can actually be a relaxing activity for many people and may help them wind down before bedtime.

Choice C reason: Dimming the screen on electronic devices can reduce exposure to blue light, which can interfere with the body's natural sleep-wake cycle. However, it is generally recommended to avoid the use of electronic devices altogether in the bedroom to promote better sleep hygiene.

Choice D reason: Meditation is a relaxation technique that can be beneficial for individuals with PTSD and sleep disturbances. It can help calm the mind, reduce stress, and prepare the body for sleep. Mindfulness meditation, in particular, has been shown to improve sleep quality and is a recommended practice for those experiencing insomnia.

A. Hallucinations B. Temperature C. Weight gain D. Blood pressure

Correct Answer is B

Explanation

Choice A Reason: Hallucinations are a common symptom of schizophrenia and may not require immediate reporting to a provider unless they represent a change from the patient’s baseline or are causing distress.
Choice B Reason: The client’s temperature of 39.4° C (103° F) is significantly higher than the normal body temperature range of 36.5° C to 37.5° C (97.7° F to 99.5° F). This indicates a fever, which could suggest an infection or another acute health issue that requires immediate attention.
Choice C Reason: While weight gain is a concern for patients with schizophrenia, especially due to the potential side effects of medications like olanzapine, it is not typically an acute issue requiring immediate reporting unless it is rapid and significant, which could indicate other health problems.
Choice D Reason: The client’s blood pressure reading of 128/82 mm Hg falls within the normal range for adults, which is less than 120/80 mm Hg for normal blood pressure. Therefore, it does not need to be reported urgently.

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A nurse is assessing a client who has a recent diagnosis of dissociative identity disorder. The client tells the nurse, "I think my blackouts are actually caused by low blood sugar." The nurse should recognize the client is using which of the following defense mechanisms?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is being treated for posttraumatic stress disorder (PTSD). The client states, "I'm not able to fall asleep easily or stay asleep." Which of the following recommendations should the nurse make?

Correct Answer is D

Explanation

Exhibits A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse report to the provider? (Click on the “Exhibit” button for additional information about the client. There are three tabs that contain separate categories of data.)

Correct Answer is B

Explanation

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