Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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?.
A. Suppression
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.
B. Reaction formation.
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.
C. Splitting.
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.
D. Projection.
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.
This question is an excerpt from Nurse Dive's nursing test bank - ATI PN Mental health DEC 2023 Proctored Exam. Take the full exam now
Full Explanation
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.
Similar Questions
A client who delivered a healthy newborn 4 weeks ago calls her provider's office and tells the nurse, "This baby constantly cries.
My partner works all the time, and I can't take any more.”. Which of the following responses is the nurse's priority?.
A. "Having a newborn must be stressful. Do you have other children?".
A rationale: While it’s important to understand the client’s situation, the immediate safety of the baby is the priority.
B. "Tell me about your baby. Where is she now?".
B rationale: This response is the priority as it assesses the immediate safety of the baby.
C. "Do you have a friend who could help you?".
C rationale: While support is important, the immediate safety of the baby is the priority.
D. "Have you discussed this with your partner?".
D rationale: While communication with the partner is important, the immediate safety of the baby is the priority.
Full Explanation
Choice A rationale:
While it’s important to understand the client’s situation, the immediate safety of the baby is the priority.
Choice B rationale:
This response is the priority as it assesses the immediate safety of the baby.
Choice C rationale:
While support is important, the immediate safety of the baby is the priority.
Choice D rationale:
While communication with the partner is important, the immediate safety of the baby is the priority.
A nurse is reinforcing teaching with the caregiver of a client who has Alzheimer's disease.
The caregiver reports that the client awakens at night and wanders.
Which of the following strategies should the nurse suggest?.
A. Use light restraints while the client is in bed.
A rationale: Using restraints can lead to injury and is generally a last resort.
B. Place a lock at the top of doors leading outside.
B rationale: Placing a lock at the top of doors can prevent the client from wandering outside and getting lost or injured.
C. Encourage the client to nap during the day.
C rationale: Encouraging napping during the day can actually disrupt the client’s sleep cycle and increase nighttime wakefulness.
D. Administer an antianxiety medication before bedtime.
D rationale: While medication can be helpful, non-pharmacological interventions should be tried first.
Full Explanation
Choice A rationale:
Using restraints can lead to injury and is generally a last resort.
Choice B rationale:
Placing a lock at the top of doors can prevent the client from wandering outside and getting lost or injured.
Choice C rationale:
Encouraging napping during the day can actually disrupt the client’s sleep cycle and increase nighttime wakefulness.
Choice D rationale:
While medication can be helpful, non-pharmacological interventions should be tried first.
A nurse is caring for a client who is experiencing a situational crisis.
Which of the following actions should the nurse take first?.
A. Reinforce teaching on the client's use of coping skills
A rationale: Reinforcing teaching on the client’s use of coping skills is important, but it’s not the first action the nurse should take. The nurse must first ensure the client’s safety.
B. Encourage the client to use personal support systems.
B rationale: Encouraging the client to use personal support systems is beneficial, but it’s not the first action. Safety is the priority.
C. Assist with a client referral for social services.
C rationale: Assisting with a client referral for social services can be helpful, but it’s not the first action. The nurse must first assess for immediate safety risks.
D. Identify if the client has thoughts of self-harm.
D rationale: Identifying if the client has thoughts of self-harm is the first action the nurse should take. In a crisis situation, the client’s safety is the priority.
Full Explanation
Choice A rationale:
Reinforcing teaching on the client’s use of coping skills is important, but it’s not the first action the nurse should take. The nurse must first ensure the client’s safety.
Choice B rationale:
Encouraging the client to use personal support systems is beneficial, but it’s not the first action. Safety is the priority.
Choice C rationale:
Assisting with a client referral for social services can be helpful, but it’s not the first action. The nurse must first assess for immediate safety risks.
Choice D rationale:
Identifying if the client has thoughts of self-harm is the first action the nurse should take. In a crisis situation, the client’s safety is the priority.