Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assessing a young adult client who has a new diagnosis of Idiopathic Juvenile arthritis. The client states. "The pain in my joints is just a temporary thing. If I keep eating right and exercising, it'll go away." The nurse should identify that the client is using which of the following defense mechanisms?
A. Displacement
A) Displacement: Displacement involves redirecting emotions or feelings from the original source to a safer or more acceptable substitute. In this scenario, the client is not redirecting their feelings about their condition onto another person or object, so displacement does not apply. .
B. Reaction formation
B) Reaction formation: Reaction formation is when a person behaves in a way that is opposite to their actual feelings or thoughts to conceal them. The client is not expressing the opposite of their true feelings about their condition; instead, they are downplaying the seriousness of their diagnosis.
C. Denial
C) Denial: Denial involves refusing to accept reality or facts, thus blocking external events from awareness. By believing that proper diet and exercise alone will make the joint pain go away, the client is refusing to accept the chronic nature of their condition and its long-term implications.
D. Rationalization
D) Rationalization: Rationalization involves creating logical reasons or excuses for behaviors or feelings to avoid facing the true reasons. The client is not making excuses or trying to justify their feelings; instead, they are denying the chronic nature of their arthritis, which makes denial the correct defense mechanism in this context.
This question is an excerpt from Nurse Dive's nursing test bank - LPN ATI Mental Health Proctored Exam. Take the full exam now
Full Explanation
Answer: C
Rationale:
A) Displacement:
Displacement involves redirecting emotions or feelings from the original source to a safer or more acceptable substitute. In this scenario, the client is not redirecting their feelings about their condition onto another person or object, so displacement does not apply.
B) Reaction formation:
Reaction formation is when a person behaves in a way that is opposite to their actual feelings or thoughts to conceal them. The client is not expressing the opposite of their true feelings about their condition; instead, they are downplaying the seriousness of their diagnosis.
C) Denial:
Denial involves refusing to accept reality or facts, thus blocking external events from awareness. By believing that proper diet and exercise alone will make the joint pain go away, the client is refusing to accept the chronic nature of their condition and its long-term implications.
D) Rationalization:
Rationalization involves creating logical reasons or excuses for behaviors or feelings to avoid facing the true reasons. The client is not making excuses or trying to justify their feelings; instead, they are denying the chronic nature of their arthritis, which makes denial the correct defense mechanism in this context.
Similar Questions
The nurse is caring for a client who has been admitted Involuntarily for psychiatric treatment. Which of the following Information about involuntary commitment should the nurse provide the client's family?
A. "A psychiatrist determines that the client's behavior is irrational.
"A psychiatrist determines that the client's behavior is irrational." This statement focuses on the client's behavior being irrational, which is not the primary criteria for involuntary commitment. It is more important to emphasize the potential harm the client may cause to themselves or others.
B. "The client is unable to manage the affairs necessary for daily life."
"The client is unable to manage the affairs necessary for daily life." While this may be a factor contributing to the need for psychiatric treatment, it is not the specific reason for involuntary commitment. The main concern is the risk of harm associated with the client's behavior.
C. "The client's behavior is a threat to self or others.
Involuntary commitment is a legal process where an individual is admitted to a psychiatric facility against their will due to a perceived risk of harm to themselves or others. The primary concern in involuntary commitment is the safety and well-being of the individual and those around them. Therefore, it is important for the nurse to inform the client's family about the reason for the involuntary commitment, emphasizing that the client's behavior poses a threat to themselves or others. incorrect:
D. "The client has been accused of breaking the law."
"The client has been accused of breaking the law." Involuntary commitment is not based on accusations of breaking the law. It is primarily focused on the safety and well-being of the individual and the potential risk they pose to themselves or others.
Full Explanation
Involuntary commitment is a legal process where an individual is admitted to a psychiatric facility against their will due to a perceived risk of harm to themselves or others. The primary concern in involuntary commitment is the safety and well-being of the individual and those around them.
Therefore, it is important for the nurse to inform the client's family about the reason for the involuntary commitment, emphasizing that the client's behavior poses a threat to themselves or others.
incorrect:
A. "A psychiatrist determines that the client's behavior is irrational." This statement focuses on the client's behavior being irrational, which is not the primary criteria for involuntary commitment. It is more important to emphasize the potential harm the client may cause to themselves or others.
B. "The client is unable to manage the affairs necessary for daily life." While this may be a factor contributing to the need for psychiatric treatment, it is not the specific reason for involuntary commitment. The main concern is the risk of harm associated with the client's behavior.
D. "The client has been accused of breaking the law." Involuntary commitment is not based on accusations of breaking the law. It is primarily focused on the safety and well-being of the individual and the potential risk they pose to themselves or others.
A nurse is preparing to change the dressing on the lower leg of an older adult client who is in a wheelchair, and has a history of maladaptive coping skills. The client begins swearing at and verbally abusing the nurse. Which of the following actions should the nurse take?
A. Explain to the client why her behavior is inappropriate.
Explaining to the client why their behavior is inappropriate may not be effective in the moment when the client is already agitated and verbally abusive. Attempting to reason with or educate the client during this state could potentially escalate the situation or prolong the abusive behavior.
B. Tell the client when he will return and leave the room.
By calmly informing the client when the nurse will return and then leaving the room, the nurse establishes clear boundaries and removes themselves from the situation to ensure their own safety. It allows the nurse to disengage from the abusive behavior and avoid escalating the situation further. Let's review the other options and explain why they are not appropriate in this situation:
C. Place wrist restraints on the client to prevent psychomotor agitation.
Placing wrist restraints on the client should only be done in exceptional circumstances when there is an imminent risk of harm to themselves or others. Verbal abuse, while unpleasant, does not necessarily warrant the use of restraints as a first-line intervention.
D. Move the client to a seclusion room.
Moving the client to a seclusion room is also an extreme measure and should only be considered if the client's behavior poses a significant risk to themselves or others and less restrictive interventions have been exhausted. Verbal abuse alone would not typically warrant seclusion.
Full Explanation
By calmly informing the client when the nurse will return and then leaving the room, the nurse establishes clear boundaries and removes themselves from the situation to ensure their own safety. It allows the nurse to disengage from the abusive behavior and avoid escalating the situation further.
Let's review the other options and explain why they are not appropriate in this situation:
A. Explaining to the client why their behavior is inappropriate may not be effective in the moment when the client is already agitated and verbally abusive. Attempting to reason with or educate the client during this state could potentially escalate the situation or prolong the abusive behavior.
C. Placing wrist restraints on the client should only be done in exceptional circumstances when there is an imminent risk of harm to themselves or others. Verbal abuse, while unpleasant, does not necessarily warrant the use of restraints as a first-line intervention.
D. Moving the client to a seclusion room is also an extreme measure and should only be considered if the client's behavior poses a significant risk to themselves or others and less restrictive interventions have been exhausted. Verbal abuse alone would not typically warrant seclusion.
A client who has rheumatoid arthritis shows the nurse at her provider's office her magnetic copper bracelet and says that it helps alleviate her pain when she wears it. Which of the following responses should the nurse make?
A. "Why do you think the copper helps with your arthritis?"
"Why do you think the copper helps with your arthritis?" This response may come across as questioning or doubting the client's belief, which can be invalidating and may hinder thenurse-client relationship.
B. "I think you should rely more on your medication therapy than on your bracelet."
"I think you should rely more on your medication therapy than on your bracelet." While it is important to emphasize evidence-based medical treatments, this response may be perceived as dismissive or confrontational. It is essential to maintain a supportive and collaborative approach.
C. "Yes, I understand that you feel better wearing your bracelet."
This response acknowledges the client's subjective experience and validates their belief that the bracelet provides pain relief. It shows empathy and respect for the client's perspective without dismissing or challenging their belief. Let's review the other options and explain why they are not the most appropriate responses:
D. "Believing objects have powers to make you feel better has no scientific basis."
"Believing objects have powers to make you feel better has no scientific basis." Although this statement is true in terms of scientific evidence, it may undermine the client's beliefs and create a sense of defensiveness or disagreement. It is more effective to maintain a respectful andnon-judgmental attitude.
Full Explanation
This response acknowledges the client's subjective experience and validates their belief that the bracelet provides pain relief. It shows empathy and respect for the client's perspective without dismissing or challenging their belief.
Let's review the other options and explain why they are not the most appropriate responses:
A. "Why do you think the copper helps with your arthritis?" This response may come across as questioning or doubting the client's belief, which can be invalidating and may hinder the
nurse-client relationship.
B. "I think you should rely more on your medication therapy than on your bracelet." While it is important to emphasize evidence-based medical treatments, this response may be perceived as dismissive or confrontational. It is essential to maintain a supportive and collaborative approach.
D. "Believing objects have powers to make you feel better has no scientific basis." Although this statement is true in terms of scientific evidence, it may undermine the client's beliefs and create a sense of defensiveness or disagreement. It is more effective to maintain a respectful and non-judgmental attitude.