A nurse is counseling a client for the management of anxiety.
The client is consistently late for appointments and ignores household chores. The client states, "I'm just too stressed.
I need someone to take care of me." The nurse identifies this behavior as an example of which of the following defense mechanisms?
Dissociation
Regression
Introjection
Repression.
The Correct Answer is B
Choice A rationale: Dissociation is a defense mechanism where a person disconnects from reality, memory, identity, or perception. It is often a response to trauma and can result in a detachment from emotional and physical experiences. The client’s behavior does not indicate a disconnection from reality or self.
Choice B rationale: Regression is a defense mechanism where an individual reverts to an earlier stage of development in response to stress or anxiety. In this case, the client’s behavior of wanting someone to take care of them can be seen as a regression to a childlike state of dependency, which is a common response to overwhelming stress or anxiety.
Choice C rationale: Introjection is a defense mechanism where a person internalizes the ideas or voices of other people- often authority figures. This is not evident in the client’s behavior.
Choice D rationale: Repression is a defense mechanism where a person unconsciously blocks out distressing thoughts or feelings. In this scenario, the client is expressing their feelings of stress rather than repressing them.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Coercion to take necessary prescribed medications is not an appropriate indication for the use of mechanical restraints. It violates the client's right to autonomy and informed consent.
Forcing a client to take medication against their will can lead to psychological trauma, distrust of healthcare providers, and even legal action.
Alternative interventions, such as patient education, negotiation, and behavioral strategies, should be explored first to encourage medication compliance.
If a client is refusing medication due to a lack of understanding, providing clear and concise information about the medication's purpose, benefits, and potential side effects can help facilitate informed decision-making.
Negotiation strategies can involve exploring the client's concerns and preferences, and working collaboratively to find a solution that addresses those concerns.
Behavioral strategies may include positive reinforcement for medication adherence, or the use of techniques such as distraction or relaxation to reduce anxiety associated with medication administration.
Choice B rationale:
Punishment for verbally abusing other clients is also not an appropriate indication for mechanical restraints.
Restraints should never be used as a form of punishment, as this can be considered abuse and can worsen the client's behavior.
Verbal abuse is often a symptom of underlying mental health issues, and it's important to address the root cause of the behavior rather than simply trying to suppress it through restraints.
Alternative interventions for verbal abuse might include de-escalation techniques, conflict resolution strategies, and individual or group therapy to address underlying emotional or behavioral issues.
Choice C rationale:
Discipline for throwing objects at staff in the nursing station is not an appropriate indication for mechanical restraints. Restraints should only be used as a last resort to protect the client or others from imminent harm.
Throwing objects may be a sign of agitation, frustration, or anger, and it's important to address the underlying cause of these behaviors.
Alternative interventions could include de-escalation techniques, providing a safe space for the client to calm down, medication to manage agitation, or behavioral therapy to teach coping skills.
Choice D rationale:
Self-destructive behavior after all previous alternative interventions have been unsuccessful is the only appropriate indication for mechanical restraints among the choices provided.
When a client is at risk of seriously harming themselves, and other interventions have failed to protect them, restraints may be necessary to prevent injury or death.
However, it's crucial to use restraints only as a temporary measure and to continuously monitor the client's condition and behavior.
As soon as the client is no longer at risk of self-harm, the restraints should be removed.
Correct Answer is ["1.5"]
Explanation
Step 1 is to determine the total amount of medication needed, which is 300 mg.
Step 2 is to determine the amount of medication available per tablet, which is 200 mg.
Step 3 is to calculate the number of tablets needed by dividing the total amount of medication needed by the amount available per tablet.
So, the calculation is: 300 mg ÷ 200 mg/tablet = 1.5 tablets Therefore, the nurse should administer 1.5 tablets.
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