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?.

Suppression

Reaction formation.

Splitting.

Projection.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Suppression is a conscious decision to delay paying attention to an emotion or need in order to cope with the present reality. In this case, the client is choosing to delay thinking about their health until after their son’s wedding.

Choice B rationale:

Reaction formation is behaving in a way that is exactly the opposite of one’s true feelings. This is not evident in the client’s statement.

Choice C rationale:

Splitting is the inability to integrate the positive and negative qualities of oneself or others into a cohesive image. This is not evident in the client’s statement.

Choice D rationale:

Projection is attributing one’s unacceptable thoughts and feelings onto another who does not have them. This is not evident in the client’s statement.

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Correct Answer is B

Explanation

Choice A rationale:

This statement indicates a delusion, not a command hallucination. Delusions are fixed false beliefs that are not based in reality.

Choice B rationale:

This statement indicates a command hallucination. Command hallucinations involve hearing voices that direct the person to take action.

Choice C rationale:

This statement indicates paranoia, not a command hallucination. Paranoia involves intense anxious or fearful feelings and thoughts often related to persecution or threat.

Choice D rationale:

This statement indicates a visual hallucination, not a command hallucination. Visual hallucinations involve seeing things that aren’t there.

A. Administer acyclovir. B. Administer lorazepam. C. Initiate 1:1 supervision. D. Administer 0.9% sodium chloride 125 mL/hr by continuous IV infusion.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}

Explanation

Potential Provider Prescription	Expected or Unexpected?	Explanation
Administer acyclovir.	Unexpected	Acyclovir is an antiviral medication used to treat infections like herpes simplex virus (HSV) and varicella-zoster virus (VZV). The client’s confusion, agitation, and hallucinations do not suggest a viral infection as the primary cause.
Administer lorazepam.	Expected	Lorazepam is a benzodiazepine that can be used for acute agitation, anxiety, or delirium-related distress. Since the client is agitated and confused, lorazepam is an appropriate intervention.
Initiate 1:1 supervision.	Expected	The client is confused, agitated, and hallucinating, which increases the risk of self-harm, wandering, or injury. 1:1 supervision ensures safety.
Administer 0.9% sodium chloride 125 mL/hr by continuous IV infusion.	Expected	The client has dry mucous membranes, suggesting possible dehydration, which can contribute to confusion and agitation. IV fluids help restore hydration.

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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 a client who has schizophrenia. Which of the following client statements indicates that the client is experiencing a command hallucination? .

Correct Answer is B

Explanation

The nurse has reviewed the nurses' notes, provider's note, and vital signs at 0400. Exhibits For each potential provider prescription, click to specify if the prescription is expected or unexpected for the client.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"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?.