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NurseDive Free Nursing Practice Question
Patient Data
The nurse engages the client in conversation about her feelings and some of her coping mechanisms.
Click to specify which client statement or behavior is most likely associated with each of the listed defense mechanisms. Some statements or behaviors may be consistent with more than one mechanism. Each column must have at least one but may have more than one answer selected.
A. The client discusses moving to Hawaii instead of returning to rebuild her house.
B. The client seems unemotional when talking about needing to rebuild her house.
C. The client states that she sometimes forgets why she is in the hospital.
D. The client is frightened that the hospital will burn down.
This question is an excerpt from Nurse Dive's nursing test bank - Rn Hesi Mental Health Proctored Exam. Take the full exam now
Full Explanation
A. The client discusses moving to Hawaii instead of returning to rebuild her house.
Defense Mechanism: Fantasy
- Explanation: The client may be using fantasy as a way to escape from the painful reality of her situation. Discussing moving to a place like Hawaii, which may represent an idealized and stress-free environment, suggests a desire to avoid confronting the challenges and emotions associated with her current circumstances.
B. The client seems unemotional when talking about needing to rebuild her house.
Defense Mechanism: Isolation
- Explanation: Isolation, or emotional isolation, occurs when an individual separates emotions from the events or thoughts associated with them. The client's lack of emotional response when discussing rebuilding her house suggests that she may be isolating her feelings to avoid distress.
C. The client states that she sometimes forgets why she is in the hospital.
Defense Mechanism: Suppression
- Explanation: Suppression involves the conscious effort to avoid thinking about distressing thoughts or memories. The client's statement that she sometimes forgets why she is in the hospital may indicate an attempt to suppress or avoid focusing on the traumatic event that led to her hospitalization.
D. The client is frightened that the hospital will burn down.
Defense Mechanism: Denial
- Explanation: Denial involves refusing to accept the reality of a situation, which can manifest as irrational fears or beliefs. The client's fear that the hospital will burn down may reflect a form of denial, as she might be projecting her fear of the collapse (a traumatic event) onto another catastrophic event, thereby avoiding dealing with her actual trauma.
Summary of Answers:
- A. Fantasy - The client discusses moving to Hawaii instead of returning to rebuild her house.
- B. Isolation - The client seems unemotional when talking about needing to rebuild her house.
- C. Suppression - The client states that she sometimes forgets why she is in the hospital.
- D. Denial - The client is frightened that the hospital will burn down.
Similar Questions
A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?
A. Assist the client with relaxation techniques in the group.
Assisting the client with relaxation techniques within the group may be ineffective for severe anxiety because the client may be too overwhelmed by the environment to participate or focus.
B. Escort the client from the group to reduce stimuli.
Escorting the client from the group to a quieter environment is the most effective intervention for severe anxiety. Reducing external stimuli allows the client to regain composure and prevents escalation of physiological and psychological stress responses.
C. Provide education about ways to cope with anxiety.
Providing education about coping strategies is appropriate for mild or moderate anxiety, but during severe anxiety the client is unlikely to process or retain information effectively.
D. Ask the client to describe and identify the source of the feelings.
Asking the client to describe or identify the source of feelings can increase anxiety and is not therapeutic during a severe anxiety episode. Exploration of triggers is more appropriate once the client is calmer.
Full Explanation
A. Assisting the client with relaxation techniques within the group may be ineffective for severe anxiety because the client may be too overwhelmed by the environment to participate or focus.
B. Escorting the client from the group to a quieter environment is the most effective intervention for severe anxiety. Reducing external stimuli allows the client to regain composure and prevents escalation of physiological and psychological stress responses.
C. Providing education about coping strategies is appropriate for mild or moderate anxiety, but during severe anxiety the client is unlikely to process or retain information effectively.
D. Asking the client to describe or identify the source of feelings can increase anxiety and is not therapeutic during a severe anxiety episode. Exploration of triggers is more appropriate once the client is calmer.
A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?
A. Assist the client with relaxation techniques in the group.
Helping the client practice relaxation techniques within the group may not be effective for severe anxiety because the environment may still be overstimulating. The client may not be able to focus or participate until anxiety decreases.
B. Escort the client from the group to reduce stimuli.
Escorting the client from the group to a quieter environment is the priority intervention for severe anxiety. Reducing environmental stimuli helps the client regain control, decreases physiological arousal, and allows the nurse to implement therapeutic interventions safely.
C. Provide education about ways to cope with anxiety.
Providing education about coping strategies is appropriate for mild to moderate anxiety but is ineffective during a severe anxiety episode because the client’s ability to process information is impaired.
D. Ask the client to describe and identify the source of the feelings.
Asking the client to describe and identify the source of anxiety can increase stress and is not appropriate during a severe anxiety state. Therapeutic exploration is better initiated once the client’s anxiety is reduced.
Full Explanation
A. Helping the client practice relaxation techniques within the group may not be effective for severe anxiety because the environment may still be overstimulating. The client may not be able to focus or participate until anxiety decreases.
B. Escorting the client from the group to a quieter environment is the priority intervention for severe anxiety. Reducing environmental stimuli helps the client regain control, decreases physiological arousal, and allows the nurse to implement therapeutic interventions safely.
C. Providing education about coping strategies is appropriate for mild to moderate anxiety but is ineffective during a severe anxiety episode because the client’s ability to process information is impaired.
D. Asking the client to describe and identify the source of anxiety can increase stress and is not appropriate during a severe anxiety state. Therapeutic exploration is better initiated once the client’s anxiety is reduced.
The mother of an 8-month-old infant with profound mental and physical disabilities tells the nurse how depressed she is because she realizes that her child will never achieve normal growth and development milestones. How should the nurse respond to this mother?
A. Encourage the mother to write thoughts and feelings in a journal.
Encouraging journaling may help with coping over time but does not address potential immediate safety concerns.
B. Determine if the mother has other children who do not have developmental disabilities.
Asking about other children is not relevant to the mother’s current emotional state and does not assess risk.
C. Reassure the mother that her child will achieve some growth and development milestones.
Reassuring the mother about milestones may minimize her feelings and does not address her depression or potential risk of harm.
D. Ask the mother if she has ever thought about harming herself or her child.
Asking the mother if she has ever thought about harming herself or her child is the priority response because it assesses for immediate risk of harm. Screening for suicidal or homicidal thoughts is essential when a parent expresses intense depression or hopelessness regarding a child’s condition.
Full Explanation
A. Encouraging journaling may help with coping over time but does not address potential immediate safety concerns.
B. Asking about other children is not relevant to the mother’s current emotional state and does not assess risk.
C. Reassuring the mother about milestones may minimize her feelings and does not address her depression or potential risk of harm.
D. Asking the mother if she has ever thought about harming herself or her child is the priority response because it assesses for immediate risk of harm. Screening for suicidal or homicidal thoughts is essential when a parent expresses intense depression or hopelessness regarding a child’s condition.