A nurse is assessing a newly admitted client who states that they do not want to live anymore and plan to end their life. Which of the following actions should the nurse take?

Reassure the client that everything is going to work out.

Ask the client about the lethality of their plan.

Allow the client time alone to self-reflect

Encourage the client to focus on the positive aspects of life.

Answer and Explanation

The Correct Answer is B

Rationale:

A. Offering reassurance without addressing the client's immediate concerns may minimize the severity of the situation and delay necessary interventions.

B. Asking the client about the lethality of their plan is crucial for assessing the level of risk and determining the urgency of the intervention required. This information is essential for planning appropriate care and ensuring the client's safety.

C. Allowing the client to be alone is not appropriate when they have expressed suicidal intent, as this could increase the risk of self-harm.

D. Encouraging the client to focus on the positive aspects of life may be part of long-term therapy, but in the acute phase, the priority is to assess and address the immediate risk of suicide.

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Correct Answer is ["C","E","F"]

Explanation

Rationale:

A. Defense mechanisms and coping strategies are not the same. Defense mechanisms are unconscious processes used to protect the individual from anxiety and internal conflicts, while coping strategies are conscious efforts to handle stress.

B. Defense mechanisms can be maladaptive and may not always help clients positively deal with stress. They can sometimes hinder adaptive functioning.

C. Defense mechanisms are indeed influenced by neurological and psychological growth. As individuals age, they develop more sophisticated and adaptive mechanisms.

D. Maladaptive defense mechanisms do not improve mental well-being; instead, they can often worsen mental health and impair functioning.

E. Adaptive defense mechanisms, such as sublimation and rationalization, help individuals manage stress more effectively and transform challenges into manageable situations.

F. Adaptive defense mechanisms are characteristic of more mature psychological functioning, reflecting a higher level of emotional resilience and coping.

A. "I can't sit still. I feel like I need to be doing things around the house." B. "Lately, I feel like I am more alert than usual and can focus better." C. "When I went to my provider, they told me I have high blood pressure." D. "I can't get my mind to stop racing at night. I'm only sleeping a couple of hours.”

Correct Answer is D

Explanation

Rationale:

A. Feeling restless and needing to be active can be more indicative of anxiety or agitation rather than depression.

B. Increased alertness and improved focus are not typical symptoms of depression; rather, depression often involves decreased energy and focus.

C. High blood pressure is not directly related to depressive symptoms.

D. Difficulty sleeping and racing thoughts at night are consistent with depression, particularly when accompanied by poor sleep quality.

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A nurse is assessing a newly admitted client who states that they do not want to live anymore and plan to end their life. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning a teaching for a group of clients about defense mechanisms. Which of the following information should the nurse include? (Select All that Apply.)

Correct Answer is ["C","E","F"]

Explanation

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Correct Answer is D

Explanation

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