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A nurse is assessing a young adult client who has a new diagnosis of Idiopathic Juvenile arthritis. The client states. "The pain in my joints is just a temporary thing. If I keep eating right and exercising, it'll go away." The nurse should identify that the client is using which of the following defense mechanisms?

Displacement

Reaction formation

Denial

Rationalization

Answer and Explanation

The Correct Answer is C

Answer: C

Rationale:

A) Displacement:

Displacement involves redirecting emotions or feelings from the original source to a safer or more acceptable substitute. In this scenario, the client is not redirecting their feelings about their condition onto another person or object, so displacement does not apply.

B) Reaction formation:

Reaction formation is when a person behaves in a way that is opposite to their actual feelings or thoughts to conceal them. The client is not expressing the opposite of their true feelings about their condition; instead, they are downplaying the seriousness of their diagnosis.

C) Denial:

Denial involves refusing to accept reality or facts, thus blocking external events from awareness. By believing that proper diet and exercise alone will make the joint pain go away, the client is refusing to accept the chronic nature of their condition and its long-term implications.

D) Rationalization:

Rationalization involves creating logical reasons or excuses for behaviors or feelings to avoid facing the true reasons. The client is not making excuses or trying to justify their feelings; instead, they are denying the chronic nature of their arthritis, which makes denial the correct defense mechanism in this context.

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Correct Answer is A

Explanation

Leaving the child's room exactly as it was before the loss suggests that the client is unable to accept and adapt to the reality of the child's death. This behavior can be considered maladaptive because it hinders the process of mourning and moving forward. It may reflect a difficulty in accepting the loss and adjusting to life without the child.

The other actions mentioned in the options are not necessarily indicative of maladaptive grieving:

B. Visiting the child's grave every week: Visiting the child's grave can be a normal part of the grieving process for some individuals. It provides an opportunity for the client to remember and honor the child's memory.

C. Talking about the child in the past tense: It is common for individuals to talk about a deceased loved one in the past tense. This does not necessarily indicate maladaptive grieving. It is a way of acknowledging the loss and recognizing that the person is no longer physically present.

D. Volunteering at a local children's hospital: Engaging in volunteer work can be a positive coping mechanism for individuals who have experienced a loss. It allows them to find meaning, connection, and a sense of purpose through helping others.

A. "The most common adverse effects of ECT are related to the anesthesia." B. "You might feel a bit confused and disoriented when you first wake up." C. "You should expect to have ECT once per week for 6 weeks." D. "You may experience muscle cramping from the induced seizure."

Correct Answer is B

Explanation

Electroconvulsive therapy (ECT) is a procedure used to treat certain mental health conditions. When providing teaching to a client scheduled to receive ECT, it is important to provide accurate information about what they can expect during and after the procedure.

The statement "You might feel a bit confused and disoriented when you first wake up" is important because confusion and disorientation are common side effects of ECT. Clients often experience some memory loss and temporary cognitive impairment after the procedure, which can cause these symptoms. By preparing the client for these potential effects, the nurse helps reduce anxiety and ensures that the client understands what is considered normal post-ECT.

Incorrect:

A. "The most common adverse effects of ECT are related to the anesthesia." While anesthesia is used during ECT to ensure the client's comfort and safety, the most common adverse effects of ECT are related to the procedure itself, such as memory loss and cognitive changes.

C. "You should expect to have ECT once per week for 6 weeks." The frequency and duration of ECT treatments vary depending on the individual client's condition and treatment plan. It is not appropriate to provide a specific treatment schedule without knowing the client's unique circumstances.

D. "You may experience muscle cramping from the induced seizure." Muscle cramping is not a common adverse effect of ECT. The induced seizure is typically brief and controlled, and muscle relaxants are administered to prevent any excessive muscle activity during the procedure.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client whose child was killed 2 years ago. Which of the following actions Indicates that the client is experiencing maladaptive grieving?

Correct Answer is A

Explanation

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?

Correct Answer is B

Explanation

A nurse is caring for a client who begins to make sexual advances towards him. Which of the following is an appropriate statement by the nurse?

A nurse is discussing legal exceptions to client confidentiality with nursing staff. Which of the following statements by a staff member indicates an understanding?

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?

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?

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 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?