A nurse is caring for a client who has a new diagnosis of cancer.
The client states, "I can't think about my health until after my son is married next week.”. The nurse should identify the client's statement as an indication of which of the following maladaptive defense mechanisms?

Splitting.

Suppression.

Reaction formation.

Projection.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Splitting is a defense mechanism where a person sees things in black-and-white, without the capacity to recognize nuances or integrate good and bad qualities together.

Choice B rationale

Suppression is a conscious decision to delay dealing with stressors or emotions until a later time, as the client does by focusing on their son’s wedding before addressing their health.

Choice C rationale

Reaction formation involves behaving in a way that's opposite to one's true feelings, which does not align with the client's expressed actions.

Choice D rationale

Projection is attributing one's own thoughts, feelings, or impulses to another person, not evident in the client's behavior.

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Correct Answer is A

Explanation

Choice A rationale

A fluctuating level of orientation is a hallmark sign of delirium. Delirium is characterized by an acute and fluctuating course of altered mental status, including changes in attention, awareness, and cognition.

Choice B rationale

A consistent state of depression is not indicative of delirium. While depression can affect mental status, it does not typically present with the acute, fluctuating changes seen in delirium.

Choice C rationale

Demonstrating obsessive behaviors is more characteristic of obsessive-compulsive disorder and does not typically indicate delirium.

Choice D rationale

Short-term memory loss can be a feature of many conditions, including dementia, but does not specifically indicate delirium, which is distinguished by its rapid onset and fluctuating nature. .

A. Verbally de-escalate the client. B. Take the client to the seclusion room. C. Place the client in restraints. D. Obtain a prescription for haloperidol.

Correct Answer is A

Explanation

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A nurse is caring for a client who has a new diagnosis of cancer.The client states, "I can't think about my health until after my son is married next week.”. The nurse should identify the client's statement as an indication of which of the following maladaptive defense mechanisms?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from an older adult client who was admitted with heart failure.The nurse should report which of the following findings to the provider as an indication of delirium?

Correct Answer is A

Explanation

A client is becoming increasingly agitated, anxious, and tense.The nurse notes a clenched jaw and a change in the pitch of the client's voice.Which of the following interventions should the nurse implement first?

Correct Answer is A

Explanation

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A nurse is caring for a client who has a new diagnosis of cancer.
The client states, "I can't think about my health until after my son is married next week.”. The nurse should identify the client's statement as an indication of which of the following maladaptive defense mechanisms?