which of the following statements should a nurse recognize as true about defense mechanisms select all that apply
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Nursing Elites

ATI RN

ATI Mental Health

1. Which of the following statements should a healthcare provider recognize as true about defense mechanisms? Select all that apply.

Correct answer: A

Rationale: Defense mechanisms are employed by the ego, not the id or superego, in response to threats to biological or psychological integrity. They aim to relieve anxiety, not increase it. By redirecting focus, they help manage mild to moderate anxiety and are often self-deceptive in nature.

2. A client has been diagnosed with depersonalization/derealization disorder. Which of the following behaviors should the nurse expect?

Correct answer: A

Rationale: Depersonalization/derealization disorder is characterized by feelings of detachment from one's body or surroundings. Individuals with this disorder may feel like they are observing themselves from outside their body or that the world around them is unreal. Therefore, the nurse should expect behaviors such as feelings of detachment from one's body (A). Fear of gaining weight (B) is more indicative of an eating disorder, paralysis of a limb (C) could be related to neurological issues, and episodes of hypomania (D) are associated with mood disorders like bipolar disorder, but not specifically with depersonalization/derealization disorder.

3. Which therapeutic communication statement might a psychiatric-mental health registered nurse use when a patient's nursing diagnosis is altered thought processes?

Correct answer: C

Rationale: Asking about the content of the voices helps understand the patient's experience and assess risk.

4. In a client's history, a significant indicator suggesting marginal coping skills and the need for careful risk assessment for violence is a history of

Correct answer: D

Rationale: A history of chemical dependence is a critical factor indicating marginal coping skills and the need for assessing the risk of violence. Substance abuse can impair judgment, increase impulsivity, and escalate the likelihood of violent behavior. It is essential to thoroughly evaluate and address substance abuse issues in clients to enhance treatment outcomes and ensure safety.

5. A client prescribed fluoxetine for depression is receiving education from a healthcare provider. Which statement by the client indicates an accurate understanding of the medication?

Correct answer: B

Rationale: The correct answer is B. Fluoxetine can cause drowsiness, affecting a person's ability to drive safely. It is essential to avoid driving until the client knows how the medication affects them to ensure safety. Choice A is incorrect because fluoxetine is usually taken in the morning due to its potential to cause insomnia. Choice C is incorrect as fluoxetine is recommended to be taken with food to minimize gastrointestinal side effects, not specifically to avoid stomach upset. Choice D is incorrect because fluoxetine is typically prescribed for depression or other mood disorders on a daily basis, not as needed for anxiety.

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