The nurse is assessing the drinking history of a client with a history of alcohol abuse. The client is being admitted after being found unresponsive in a public place. Which statement would indicate the use of defense mechanisms?

"I have no intention to stop drinking. I like the way it makes me feel."

"I have tried so many times to stop drinking. It is so hard."

I don't really have a problem with alcohol. I've just been having a streak of bad luck lately."

"I really need some help. My drinking is tearing my family apart."

Answer and Explanation

The Correct Answer is C

A. "I have no intention to stop drinking. I like the way it makes me feel.": This is an example of denial but does not strongly indicate a defense mechanism.

B. "I have tried so many times to stop drinking. It is so hard.": This demonstrates acknowledgment of the problem and a desire for change, not a defense mechanism.

C. "I don't really have a problem with alcohol. I've just been having a streak of bad luck lately.": This is an example of rationalization, a defense mechanism where the individual justifies their behavior with excuses.

D. "I really need some help. My drinking is tearing my family apart.": This statement reflects insight and readiness for change, not a defense mechanism.

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Correct Answer is D

Explanation

A. Refer client to mental health care provider for evaluation and treatment: While this is important, it is not the immediate priority. Identifying imminent risks, such as suicidal ideation, takes precedence.

B. Assist the client to identify negative effects of chemical dependency: This intervention is more suitable after immediate safety concerns, such as suicide risk, are addressed.

C. Identify support groups in the community for long-term treatment: This is a secondary intervention after immediate risks have been mitigated.

D. Determine the presence and degree of suicidal risk: Ensuring the client’s safety is the priority, as depression and recent stressors (job loss) significantly increase the risk of suicide.

A. Hallucinations B. Tremors C. Anorexia D. Insomnia

Correct Answer is A

Explanation

A. Hallucinations. Hallucinations are a sign of severe alcohol withdrawal, such as delirium tremens (DTs), which can be life-threatening and requires immediate medical attention.

B. Tremors. Tremors are a common withdrawal symptom but are not as critical as hallucinations.

C. Anorexia. Loss of appetite is a minor symptom and not life-threatening.

D. Insomnia. Although common in withdrawal, insomnia is not an urgent priority compared to hallucinations.

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The nurse is assessing the drinking history of a client with a history of alcohol abuse. The client is being admitted after being found unresponsive in a public place. Which statement would indicate the use of defense mechanisms?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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