A nurse is caring for a client who has a new diagnosis of metastatic lung cancer. The client states, "I can't think about that until after my first grandchild is born next week." The nurse should identify the client's statement as indicating the maladaptive use of which of the following defense mechanisms?

Compensation

Sublimation

Regression

Suppression

Answer and Explanation

The Correct Answer is D

A.   Compensation involves overachieving in one area to make up for deficiencies in another area, which is not evident in the client's statement.
B.   Sublimation involves channeling unacceptable impulses into socially acceptable activities, which is not demonstrated in the client's statement.
C.   Regression involves reverting to an earlier stage of development in the face of stress, which is not evident in the client's statement.
D.   Suppression involves consciously avoiding or postponing dealing with a stressor, which aligns with the client's statement of delaying thinking about their diagnosis until after a significant event.

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Correct Answer is B

Explanation

A. Oxygen saturation is not directly related to the client's reported consumption of pepperoni pizza and phenelzine.
B. Phenelzine is a monoamine oxidase inhibitor (MAOI), and consuming foods high in tyramine, such as pepperoni pizza, can lead to a hypertensive crisis. Therefore, assessing the client's blood pressure is essential to monitor for potential hypertensive effects.
C. Bowel sounds are not directly related to the client's reported consumption of pepperoni pizza and phenelzine.
D. Pupil response is not directly related to the client's reported consumption of pepperoni pizza and phenelzine.

A. Provide written information about the client's treatment plan. B. Encourage countertransference when developing the nurse-client relationship. C. Monitor the client for splitting behaviors. D. Isolate the client from social or group interactions.

Correct Answer is A

Explanation

A. Providing written information about the treatment plan promotes transparency and helps to establish trust with the client, which is important in the care of individuals with paranoid personality disorder.
B. Encouraging countertransference can blur professional boundaries and may exacerbate distrust or suspicion in clients with paranoid personality disorder.

C. Monitoring for splitting behaviors is important in personality disorders but does not directly address the client's needs or promote therapeutic engagement.
D. Isolating the client from social or group interactions can exacerbate feelings of paranoia and may not be therapeutic or appropriate.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has depression and takes phenelzine. The client reports eating pepperoni pizza while out on a pass during lunchtime. Which of the following assessments should the nurse perform?

Correct Answer is B

Explanation

A nurse is developing a plan of care for a client who has paranoid personality disorder. Which of the following actions should the nurse include in the plan?

Correct Answer is A

Explanation

A nurse is providing teaching to the caregiver of an older adult client who has Alzheimer's disease and is being cared for at home. The client wanders at night and has a history of previous falls. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

A nurse observes the caregiver of a client who has Alzheimer's disease throwing magazines on the floor and crying. Which of the following actions should the case manager take first?

A nurse is assisting with obtaining informed consent for a client who has been declared legally incompetent. Which of the following actions should the nurse take?

A nurse is preparing for an interprofessional meeting to discuss the plan of care for a client. Which of the following information should the nurse plan to communicate to a social worker?

A nurse is leading a grief support group for bereaved clients. Which of the following client statements should the nurse report to the provider as an indication of clinical depression?

A nurse is creating a plan of care for a client who has major depressive disorder. Which of the following interventions should the nurse include in the plan?

A nurse is providing behavioral therapy for a client who has obsessive-compulsive disorder. The client repeatedly checks that the doors are locked at night. Which of the following instructions should the nurse give the client when using thought stopping technique?