The Psychiatrist calls Jake’s father to obtain collateral information, pending Jake’s discharge home. Jake’s father reports Jake’s mother died when he was 14 years old. Jake is unable to tell the nurse or Psychiatrist how old he was or the year she died. Which defense mechanism is being depicted?

Regression

Projection

Repression

Suppression

Answer and Explanation

The Correct Answer is C

Choice A reason:
Regression involves reverting to an earlier stage of development in response to stress. This defense mechanism is not indicated by Jake’s inability to recall specific details about his mother’s death.
Choice B reason:
Projection involves attributing one’s own unacceptable thoughts, feelings, or flaws to others. This defense mechanism does not explain Jake’s inability to remember details about his mother’s death.
Choice C reason:
Repression is a defense mechanism where distressing memories, thoughts, or feelings are unconsciously pushed out of conscious awareness. Jake’s inability to recall how old he was or the year his mother died suggests that he may be repressing these painful memories.
Choice D reason:
Suppression is a conscious effort to push distressing thoughts or feelings out of awareness. Since Jake is unable to recall specific details, it is more likely that repression, an unconscious process, is at play.

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Correct Answer is D

Explanation

Choice A reason:
An illusion is a misinterpretation of a real external stimulus. For example, seeing a shadow and thinking it is a person. The client’s statement does not indicate a misinterpretation of reality but rather a desire to inflict harm on themselves.
Choice B reason:
A hallucination is a false sensory perception without any real external stimulus, such as hearing voices or seeing things that are not there. The client’s statement does not suggest they are experiencing a hallucination but rather expressing a desire to self-harm.
Choice C reason:
Attention-seeking behavior involves actions taken to gain attention from others. While the client’s statement could be seen as a cry for help, it is more accurately identified as a risk for self-mutilation due to the explicit mention of wanting to cut themselves.
Choice D reason:
Self-mutilation refers to deliberate self-inflicted harm, often as a way to cope with emotional pain. The client’s statement, “Give me your pen to cut the pain out of my chest,” clearly indicates a risk for self-mutilation, as they are expressing a desire to harm themselves to alleviate emotional distress.

A. A teenager who refuses to participate in the planned therapy B. A 24-year-old client who refuses to take the prescribed medication C. A 45-year-old client who is homeless and has been diagnosed with a mental disorder D. An elderly client who is confused, screaming obscenities in the street, and disturbing neighbors

Correct Answer is D

Explanation

Choice A reason:

A teenager who refuses to participate in the planned therapy does not necessarily meet the criteria for involuntary commitment. Refusal to participate in therapy can be addressed through other means, such as motivational interviewing or adjusting the treatment plan to better engage the client.

Choice B reason:

A 24-year-old client who refuses to take the prescribed medication also does not automatically qualify for involuntary commitment. Non-compliance with medication can be managed through education, support, and exploring the reasons behind the refusal. Involuntary commitment is typically reserved for situations where the client poses a danger to themselves or others.

Choice C reason:

A 45-year-old client who is homeless and has been diagnosed with a mental disorder may need support and resources, but homelessness and a mental health diagnosis alone do not justify involuntary commitment. The focus should be on providing housing and mental health services rather than involuntary hospitalization.

Choice D reason:

An elderly client who is confused, screaming obscenities in the street, and disturbing neighbors is exhibiting behavior that may pose a risk to themselves or others. This situation suggests a level of acute distress or potential danger that could warrant involuntary commitment to ensure the client’s safety and provide necessary treatment.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has bipolar disorder. The client says to the nurse, “Give me your pen to cut the pain out of my chest.” The nurse should identify that the client is at risk for which of the following?

Correct Answer is D

Explanation

Which client would a nurse determine to be the most likely candidate for involuntary commitment?

Correct Answer is D

Explanation

After being scolded by his supervisor at work, a man comes home and punches several holes in his walls and yells at his significant other. Which of the following defense mechanisms does this scenario depict?

When communicating with a client, which would a nurse use to convey positive body language?

A nurse is interviewing a client who is experiencing negative symptoms of psychosis about their family history of schizophrenia. In which of the following phases of the nursing process should this take place?

When providing care to a client diagnosed with a mental disorder, the client asks the nurse, “Does mental illness run in your family?” Which response by the nurse would be nontherapeutic?

A nurse is preparing to discharge a client who has been diagnosed with schizophrenia. The client asks, “I am not sure why I need to have a relapse plan.” Which of the following responses should the nurse make?

A nurse is planning care for a client who has paranoid schizophrenia. Which of the following interventions should be included in the plan of care?

A nurse is developing a plan of care integrating Maslow’s hierarchy of needs. Which area would the nurse identify as the priority?

A nurse is caring for a client who has schizophrenia and is taking haloperidol. The nurse should monitor for which of the following adverse effects of haloperidol?