Question

A woman who attends a stress management group reveals to group members that though she recently divorced, she continues to care for her husband's aging parents. Which psychological mechanism should the nurse address in the plan of care?

Answer 1

Correct Answers:

Altruism.

Rationale :

🧠Altruism is a mature defense mechanism in which individuals cope with stressors by helping others.

🧍‍♀️The client's continued care for her ex-husband’s parents reflects self-sacrificing behavior that may suppress personal needs or emotional pain.

🧘‍♀️This mechanism is often socially acceptable but may mask deeper feelings of guilt or unresolved dependency.

📘Addressing altruism in the care plan helps the nurse explore the client’s motivations and assess for emotional overextension.

📌Core Message

Altruism can be a way to cope with emotional conflict while appearing selfless.

Answer 2

Correct Answers:

A sense of loss.

Rationale :

💔The client has experienced multiple major life changes, each involving significant loss, including a relationship, job, and prior marriage.

🧠Loss, especially when compounded over time, is a major risk factor for developing depression.

📉These events likely disrupted the client’s identity, routine, and emotional stability, leading to a cumulative emotional burden.

📘Understanding the presence of unresolved loss is crucial for guiding the therapeutic approach and interventions.

📌Core Message

A cumulative sense of loss is a common and powerful trigger for depressive episodes.

Answer 3

Correct Answers:

Wait for the client to respond.

Rationale :

🤫Clients with depression often have psychomotor retardation, making them slow to speak or respond.

🧘‍♀️Using therapeutic silence communicates patience and encourages the client to open up in their own time.

🧠Interrupting or changing the subject may convey impatience or disinterest, weakening therapeutic rapport.

📘Silence is an active, therapeutic tool that respects the client’s processing speed and emotional state.

📌Core Message

Therapeutic silence supports client autonomy and emotional safety during depressive episodes.

Answer 4

Correct Answers:

Call for transportation to the hospital.

Rationale :

🚑During acute emotional crises, individuals may be too overwhelmed to make logical decisions or take action.

🧠Offering concrete, supportive guidance helps the client mobilize and reduces emotional overload.

📞Rather than probing for thoughts, the priority is to facilitate immediate access to the child and hospital.

📘This response demonstrates crisis intervention, which focuses on stability and immediate support.

📌Core Message

In a crisis, the nurse must offer practical support that enables immediate action.

Answer 5

Correct Answers:

Educate the client about the purpose and side effects of the medication.

Rationale :

📘Client education is essential when starting new medications, especially in substance use recovery.

🧠Understanding the medication’s purpose improves adherence and motivation to remain sober.

⚠️Explaining potential side effects prepares the client to handle challenges and reduces noncompliance.

🗣️This intervention builds trust and empowers the client to be active in their recovery process.

📌Core Message

Medication education is vital to promote adherence and relapse prevention.

Answer 6

Correct Answers:

Thiamine.

Rationale :

🧠Wernicke-Korsakoff syndrome results from chronic alcohol use and is caused by thiamine (vitamin B1) deficiency.

💉Thiamine must be administered to prevent or reverse cognitive impairments like confusion and memory loss.

📘It is the only pharmacologic treatment that addresses the underlying cause of the syndrome.

⚠️Delaying treatment can result in irreversible neurological damage or progression to Korsakoff psychosis.

📌Core Message

Thiamine is essential to reverse or prevent alcohol-induced neurological damage.

Answer 7

Correct Answers:

Give concise and firm directions for hygiene and dressing.
Assign the client to a single room.
Invite the client for a walk when client's energy is high.

Rationale :

📘Clients in a manic state need a structured, low-stimulation environment to prevent escalation.

🧠Providing clear, firm instructions helps manage disorganized behaviors and reduce confusion.

🚶‍♂️Inviting the client for walks redirects energy into safe, manageable outlets.

🚪A single room helps minimize stimulation and protects both the client and others from inappropriate behavior.

📌Core Message

Manic clients require structure, redirection, and reduced stimulation for safety and stabilization.

Answer 8

Correct Answers:

Remain calm and use a matter-of-fact approach.

Rationale :

🧘‍♀️Clients experiencing anxiety benefit from a calm, confident demeanor that conveys safety and control.

🧠Avoiding emotional escalation helps prevent further anxiety or panic during admission.

🗣️A matter-of-fact tone communicates groundedness and professionalism, which clients often interpret as reassurance.

📘This is particularly important during initial assessments, when fears are at their highest.

📌Core Message

A calm, factual approach during admission helps reduce acute anxiety.

Answer 9

Correct Answers:

Assess and report the client's electrolyte status to the healthcare provider.

Rationale :

🧪Electrolyte imbalances, especially hypokalemia, are common in bulimia nervosa and can be life-threatening.

🧠Purging behaviors (vomiting or laxative use) rapidly deplete potassium and chloride, risking arrhythmias.

🩺Immediate lab monitoring and reporting enable early intervention to prevent cardiac complications.

📘Physical safety always takes precedence over psychosocial interventions in eating disorders.

📌Core Message

Electrolyte monitoring is the top priority in clients with bulimia nervosa due to cardiac risks.

Answer 10

Correct Answers:

Tiredness.

Rationale :

🧠Fatigue or tiredness is one of the most common somatic symptoms of major depressive disorder.

🛏️This symptom reflects low energy, anhedonia, and disrupted sleep patterns, which are core elements of depression.

📘It helps differentiate depressive fatigue from symptoms caused by physical illness like headaches or dizziness.

🩺Recognizing tiredness as an emotional symptom guides appropriate psychiatric rather than medical intervention.

📌Core Message

Fatigue is a hallmark somatic indicator of clinical depression.

1 :
A woman who attends a stress management group reveals to group members that though she recently divorced, she continues to care for her husband's aging parents. Which psychological mechanism should the nurse address in the plan of care?

3 :
The nurse interacts with a client who is very depressed and slow to respond to questions. The nurse asks the client to describe current feelings, but the client looks down at the table. Which action is best for the nurse to implement?

4 :
The occupational health nurse is working with an employee who was just notified that their child was involved in a motor vehicle collision and taken to the hospital. The employee states, "I can't believe this. What should I do?" Which response is best for the nurse to provide in this crisis?

5 :
The nurse is preparing a client for discharge after treatment for cocaine abuse. The client is taking home a prescription for a new medication to control cocaine cravings. Which intervention is most important for the nurse to implement?

6 :
A client with chronic alcohol dependence is diagnosed with Wernicke-Korsakoff syndrome. The client is experiencing memory loss and confusion. Which medication should the nurse administer to help alleviate the client's symptoms?

7 :
The nurse is planning the care for a client who is hospitalized with a bipolar disorder. The client wanders the hallways, talks excessively, and makes sexual comments about the staff. Which intervention(s) should the nurse include in the plan of care? Select all that apply.

8 :
During admission to the psychiatric unit, a client is extremely anxious and reports being worried about the sun coming up the next day. Which intervention is most important for the nurse to implement during the admission process?

9 :
A young adult client is admitted to a psychiatric facility with a diagnosis of bulimia nervosa. Which nursing intervention has the highest priority?

10 :
The nurse is reviewing an intake mental health assessment with a client who is seeking services for depression. The client reports feeling dizzy, excessively tired, experiencing headaches, and back pain. Which symptom should the nurse suspect is related to the client's feelings of depression?

1 : A woman who attends a stress management group reveals to group members that though she recently divorced, she continues to care for her husband's aging parents. Which psychological mechanism should the nurse address in the plan of care?

3 : The nurse interacts with a client who is very depressed and slow to respond to questions. The nurse asks the client to describe current feelings, but the client looks down at the table. Which action is best for the nurse to implement?

4 : The occupational health nurse is working with an employee who was just notified that their child was involved in a motor vehicle collision and taken to the hospital. The employee states, "I can't believe this. What should I do?" Which response is best for the nurse to provide in this crisis?

5 : The nurse is preparing a client for discharge after treatment for cocaine abuse. The client is taking home a prescription for a new medication to control cocaine cravings. Which intervention is most important for the nurse to implement?

6 : A client with chronic alcohol dependence is diagnosed with Wernicke-Korsakoff syndrome. The client is experiencing memory loss and confusion. Which medication should the nurse administer to help alleviate the client's symptoms?

7 : The nurse is planning the care for a client who is hospitalized with a bipolar disorder. The client wanders the hallways, talks excessively, and makes sexual comments about the staff. Which intervention(s) should the nurse include in the plan of care? Select all that apply.

8 : During admission to the psychiatric unit, a client is extremely anxious and reports being worried about the sun coming up the next day. Which intervention is most important for the nurse to implement during the admission process?

9 : A young adult client is admitted to a psychiatric facility with a diagnosis of bulimia nervosa. Which nursing intervention has the highest priority?

10 : The nurse is reviewing an intake mental health assessment with a client who is seeking services for depression. The client reports feeling dizzy, excessively tired, experiencing headaches, and back pain. Which symptom should the nurse suspect is related to the client's feelings of depression?

1 :
A woman who attends a stress management group reveals to group members that though she recently divorced, she continues to care for her husband's aging parents. Which psychological mechanism should the nurse address in the plan of care?

3 :
The nurse interacts with a client who is very depressed and slow to respond to questions. The nurse asks the client to describe current feelings, but the client looks down at the table. Which action is best for the nurse to implement?

4 :
The occupational health nurse is working with an employee who was just notified that their child was involved in a motor vehicle collision and taken to the hospital. The employee states, "I can't believe this. What should I do?" Which response is best for the nurse to provide in this crisis?

5 :
The nurse is preparing a client for discharge after treatment for cocaine abuse. The client is taking home a prescription for a new medication to control cocaine cravings. Which intervention is most important for the nurse to implement?

6 :
A client with chronic alcohol dependence is diagnosed with Wernicke-Korsakoff syndrome. The client is experiencing memory loss and confusion. Which medication should the nurse administer to help alleviate the client's symptoms?

7 :
The nurse is planning the care for a client who is hospitalized with a bipolar disorder. The client wanders the hallways, talks excessively, and makes sexual comments about the staff. Which intervention(s) should the nurse include in the plan of care? Select all that apply.

8 :
During admission to the psychiatric unit, a client is extremely anxious and reports being worried about the sun coming up the next day. Which intervention is most important for the nurse to implement during the admission process?

9 :
A young adult client is admitted to a psychiatric facility with a diagnosis of bulimia nervosa. Which nursing intervention has the highest priority?

10 :
The nurse is reviewing an intake mental health assessment with a client who is seeking services for depression. The client reports feeling dizzy, excessively tired, experiencing headaches, and back pain. Which symptom should the nurse suspect is related to the client's feelings of depression?