A nurse is caring for a client who is receiving inpatient treatment for an eating disorder. The client states, "I just can't sleep soundly here because It's too noisy." Which of the following actions should the nurse take?

Recommend that the client try to sleep during the day when it is quieter.

Keep conversations and activities to a minimum during the nighttime.

Turn on the client's television at night to cover up environmental noises.

Tell the client that they will eventually get used to people talking at night.

Answer and Explanation

The Correct Answer is B

A.   Encouraging the client to sleep during the day disrupts the natural sleep-wake cycle and may not address the underlying issue of noise disturbances at night.

B.   Minimizing conversations and activities during the nighttime promotes a quieter environment conducive to sleep, addressing the client's concern directly.
C.   Using a television to cover up noise may not address the root cause of the client's sleep disturbance and could interfere with sleep hygiene.
D.   Dismissing the client's concern and suggesting they will eventually get used to the noise does not address the immediate issue or offer practical solutions.

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Correct Answer is C

Explanation

A. Orientation to person, place, and time is important for assessing mental status but may not necessarily indicate the need for restraint removal.
B. Self-harm threats should be taken seriously but may require further assessment and intervention rather than immediate restraint removal.
C. The ability to follow commands indicates a level of cooperation and self-control, which may warrant removal of restraints as the client can potentially be managed without them.
D. Refusal to take medication may necessitate further intervention but may not directly indicate the need for restraint removal unless it poses an immediate risk to the client's safety.

A. Displacement B. Compensation C. Denial D. Rationalization

Correct Answer is A

Explanation

A. Displacement involves redirecting emotions or behaviors from the original source to a less threatening or more accessible target. In this scenario, the client is redirecting his anger from his partner to the nurse, who is perceived as a safer target.
B. Compensation involves overachieving in one area to compensate for deficiencies in another area and is not demonstrated in this scenario.
C. Denial involves refusing to acknowledge the existence of a real situation or the feelings associated with it, which is not evident in the client's behavior.
D. Rationalization involves creating logical or socially acceptable explanations for behaviors or feelings that are unacceptable, which is not demonstrated in the client's behavior in this scenario.

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A nurse is caring for a client who is receiving inpatient treatment for an eating disorder. The client states, "I just can't sleep soundly here because It's too noisy." Which of the following actions should the nurse take?

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A nurse is caring for a client who has physical restraints applied. The nurse determines that the restraints should be removed when which of the following occurs?

Correct Answer is C

Explanation

A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanisms is the client demonstrating?

Correct Answer is A

Explanation

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