which client statement suggests to the nurse that the client is using the defense mechanism of projection to deal with anxiety related to admission to
Logo

Nursing Elites

HESI RN

Quizlet HESI Mental Health

1. Which client statement suggests to the nurse that the client is using the defense mechanism of projection to deal with anxiety related to admission to a psychiatric unit?

Correct answer: B

Rationale: The correct answer is B because the client is projecting their aggressive impulses onto an inanimate object, the wall, instead of accepting their own feelings. This statement reflects the defense mechanism of projection. Choice A is not projection; it is an explanation of why the client is there. Choice C indicates acceptance of the facility and does not involve projection. Choice D is a denial statement rather than projection.

2. A male client with bipolar disorder who began taking lithium carbonate five days ago is complaining of excessive thirst, and the nurse finds him attempting to drink water from the bathroom sink faucet. Which intervention should the nurse implement?

Correct answer: B

Rationale: Encouraging the client to suck on hard candy is the appropriate intervention as it can help alleviate the sensation of excessive thirst, which is a common side effect of lithium. Reporting the client’s serum lithium level to the healthcare provider may be needed if there are signs of lithium toxicity, but the priority here is to address the immediate symptom of excessive thirst. Polydipsia, or excessive thirst, is a known side effect of lithium, but it should not be left unaddressed. Simply telling the client that drinking from the faucet is not allowed does not address the underlying issue of excessive thirst and may lead to further distress.

3. A male client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. What intervention is best for the RN to implement?

Correct answer: C

Rationale: The correct intervention for the RN to implement in this situation is to avoid recognizing the behavior. By not reinforcing the echolalia through recognition, the behavior is less likely to be perpetuated, and it can reduce annoyance to other clients on the unit. Isolating the client may lead to feelings of rejection and exacerbate the behavior. Administering a PRN sedative should not be the first line of intervention for echolalia, as it does not address the underlying cause. Escorting the client to his room does not actively address the behavior or provide a therapeutic response.

4. A male adolescent was admitted to the unit two days ago for depression. When the mental health nurse tries to interview the client to establish rapport, he becomes very irritated and sarcastic. Which action is best for the nurse to take?

Correct answer: A

Rationale: Offering to play a game of cards with the adolescent is the best action for the nurse to take in this situation. Engaging in an activity like playing a game can help establish rapport with the adolescent as it provides a more relaxed and non-threatening environment for communication. This approach can help the adolescent feel more comfortable and open up, as adolescents often find it easier to communicate when involved in an activity. Reporting the behavior to the next shift, documenting the behavior, or planning to talk with the client the next day do not directly address the immediate need to establish rapport and improve communication with the adolescent.

5. A male client with a long history of alcohol dependency arrives in the emergency department describing the feeling of bugs crawling on his body. His BP is 170/102, pulse rate is 110 bpm, and his blood alcohol level (BAL) is 0 mg/dl. Which medication should the nurse administer?

Correct answer: D

Rationale: In this scenario, the client is experiencing hallucinations and symptoms of alcohol withdrawal. Lorazepam (Ativan) is the appropriate choice as it helps manage withdrawal symptoms, including hallucinations and elevated blood pressure in alcohol-dependent clients. Haloperidol (Haldol) (Choice A) is an antipsychotic but is not the first-line treatment for alcohol withdrawal symptoms. Thiamine (Vitamin B1) (Choice B) is essential in alcohol withdrawal treatment for preventing Wernicke's encephalopathy, but in this case, addressing the acute withdrawal symptoms is the priority. Diphenhydramine (Benadryl) (Choice C) is an antihistamine that may help with itching or mild anxiety but is not the preferred choice for managing alcohol withdrawal symptoms like hallucinations and elevated blood pressure.

Similar Questions

A healthcare professional is preparing to provide medication education to a client who has just been prescribed an antipsychotic medication. What should the healthcare professional include in the teaching plan?
An adolescent client is admitted to the psychiatric unit for self-harming behaviors. Which of the following is a priority nursing intervention?
A male veteran who recently returned from a war zone has post-traumatic stress disorder (PTSD) and is admitted to the psychiatric ward due to admitted suicidal ideation. On admission, the client’s family informed the healthcare provider that therapy sessions did not seem to be helping. Select only one intervention that has the highest priority.
The RN is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. Which strategies should be included in the safety plan? (SOA)
A client tells the RN that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. What is the priority nursing problem for admission to the psychiatric unit?

Access More Features

HESI RN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI RN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses