A nurse is caring for an adult client who is receiving treatment for alcohol use disorder. The client is upset because his partner has refused to visit him in the treatment facility. Which of the following actions by the client should indicate to the nurse that the client is using regression as a defense mechanism?

The client states that he has developed sudden hearing loss

The client states that his partner will not visit because they are too busy with their job

The client yells obscenities at the nurse

The client stomps his fees and throws objects of the bedside table

Answer and Explanation

The Correct Answer is D

A. The client states that he has developed sudden hearing loss: This could potentially be an example of somatization, where psychological distress is expressed through physical symptoms. However, sudden hearing loss alone might not specifically indicate regression.

B. The client states that his partner will not visit because they are too busy with their job: This statement does not directly suggest regression. It appears to be an explanation or justification for the partner's behavior.

C. The client yells obscenities at the nurse: Yelling obscenities could indicate frustration or anger, but it does not necessarily suggest regression. It could be a response to the current situation rather than a regressive behavior.

D. The client stomps his feet and throws objects off the bedside table: This behavior could indicate regression. Stomping feet and throwing objects are more characteristic of childish or immature behavior, which suggests a regression to an earlier stage of emotional development.

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Correct Answer is D

Explanation

A. “I agree with you I'm sure this will never happen again.”: This response dismisses the seriousness of the situation and does not address the potential risk to the child's safety. It's important not to make assumptions about future behavior without further investigation.

B. “This is awful. You should file charges against your partner.”: While it's important to address the safety of the child, suggesting legal action may escalate the situation and could potentially put the child or parent at risk. It's important to handle such situations delicately and considerately.

C. “This is clearly child endangerment. I will have to call the police.”: While the safety of the child is paramount, involving the authorities should be done cautiously and with consideration for the family's dynamics. Calling the police immediately may not always be the most appropriate first step, especially without further assessment or discussion with the parent.

D. “I’d like to know more about what happened. Let’s sit and talk.”: This response is the most appropriate. It demonstrates a non-judgmental and supportive approach while also indicating a commitment to understanding the situation further. Sitting down to talk allows the nurse to gather more information, assess the child's safety, and provide appropriate support and resources to the family.

A. “I can hear him crying in the middle of the night.” B. "He spends most of his time locked in his room.” C. “He refuses to go to the movies with his friends.” D. “I noticed several cutting marks on both of his arms.”

Correct Answer is D

Explanation

A. “I can hear him crying in the middle of the night.”: While this statement indicates distress, it does not necessarily indicate an immediate risk of suicide. Crying can be a symptom of various emotional or psychological issues, but it does not provide direct evidence of suicidal intent.

B. "He spends most of his time locked in his room.”: Social withdrawal or isolating oneself from others can be a warning sign of depression or other mental health issues, including suicidal ideation. However, it alone may not indicate imminent risk of suicide.

C. “He refuses to go to the movies with his friends.”: Social withdrawal or a decline in interest in previously enjoyed activities can also be indicators of depression or other mental health concerns. However, like spending time alone, it does not provide direct evidence of suicidal intent.

D. “I noticed several cutting marks on both of his arms.”: This statement is the most concerning and indicates a potential self-harm behavior. Self-harm, such as cutting, can be a significant risk factor for suicide, especially if the behavior escalates or if the individual expresses suicidal thoughts or intentions.

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Naxlex Comprehensive Predictor Exams

A nurse in an urgent-care clinic is caring for a school-age child who has several visible bruises. The child's parent states. "My partner got fret today and came home angry. I don't think this will happen again" Which of the following responses should the nurse make?

Correct Answer is D

Explanation

A nurse in a well-child clinic receives a phone call from the parent of an adolescent client. The parent states. "I think my son might try to kill himself." Which of the following statements by the parent is the priority for the nurse to investigate further?

Correct Answer is D

Explanation

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