Question

A nurse is caring for a client who escapes anxiety-causing thoughts by ignoring their existence. The nurse should recognize this behavior as which of the following defense mechanisms?

Answer 1

Correct Answers:

Denial

Rationale :

🔵 Denial is a defense mechanism in which an individual refuses to acknowledge reality or facts that are too threatening or anxiety-inducing.

🔵 The client ignores the existence of anxiety-causing thoughts, which fits the hallmark trait of denial: conscious or unconscious refusal to accept a painful reality.

🔵 Denial is often used temporarily in response to stressful or traumatic experiences, as a protective psychological buffer.

🔵 The nurse should recognize this behavior as an unconscious coping strategy, and gently guide the client toward healthier processing of underlying emotions.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 2

Correct Answers:

"Let's work together to devise a schedule that is convenient for you on a daily basis."

Rationale :

🟢 This response demonstrates collaborative care, which empowers the client to participate in their treatment plan.

🟢 It promotes medication adherence by helping the client integrate the regimen into their daily routine, making it more manageable.

🟢 The approach is nonjudgmental, supportive, and practical, which builds trust and reduces client anxiety or shame about past nonadherence.

🟢 Collaborative planning is a key aspect of therapeutic communication and patient-centered care, especially in mental health settings.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 3

Correct Answers:

"I will assist you in getting out of bed and getting dressed."

Rationale :

🟢 This response reflects supportive, therapeutic communication and promotes client engagement in a nonjudgmental, compassionate manner.

🟢 It acknowledges the client's current limitations due to depression, such as low energy and motivation, while gently encouraging participation in self-care.

🟢 Offering assistance instead of demanding action helps foster trust, shows empathy, and respects the client’s dignity and autonomy.

🟢 This approach aligns with best practices for managing depression: small, achievable goals with nurse support to gradually restore function.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 4

Correct Answers:

"It sounds like you're having a difficult time."

Rationale :

🔷 This response demonstrates therapeutic communication by using reflection and empathy to validate the client’s feelings.

🔷 It encourages the client to open up and share more about their anxiety, which can help the nurse further assess and support the client’s emotional needs.

🔷 The nurse does not offer judgment or solutions but instead acknowledges distress, which is a foundational step in building rapport and trust.

🔷 This approach supports emotional expression and can be especially calming for a client experiencing heightened anxiety or sleep disturbances.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 5

Correct Answers:

Whether the client is a danger to herself or others.

Rationale :

🔴 Involuntary admission laws allow continued hospitalization only if the client poses a danger to self or others, or is gravely disabled due to mental illness.

🔴 At the end of the 72-hour hold, a court or psychiatric review is required to determine if the client meets criteria for extended involuntary treatment.

🔴 This protects both the client's legal rights and public safety, ensuring that care is not prolonged without clinical justification.

🔴 Being a danger to self or others is a key legal and medical threshold in mental health law and commitment decisions.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 6

Correct Answers:

“I just sit here with you for a few minutes then."

Rationale :

🟤 This response shows presence and support without pressuring the client to speak before they're ready.

🟤 Offering to sit silently communicates compassion, empathy, and acceptance, which can be more therapeutic than forcing verbal interaction.

🟤 This technique is known as therapeutic silence, and it helps the client feel safe and understood, fostering trust in the nurse-client relationship.

🟤 It respects the client’s current emotional state while still conveying that they are not alone.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 7

Correct Answers:

Maintain boundaries with the client regarding personal space.

Rationale :

🟦 When caring for clients with major depressive disorder, it is essential for the nurse to establish clear professional boundaries to maintain therapeutic integrity.

🟦 Respecting the client’s personal space helps reduce anxiety, promotes comfort, and encourages trust and safety in the nurse-client relationship.

🟦 Therapeutic relationships must remain objective and client-focused, avoiding overinvolvement or emotional entanglement.

🟦 Maintaining appropriate boundaries is a cornerstone of mental health nursing and protects both the nurse and the client from role confusion.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 8

Correct Answers:

“l’ll just sit here with you for a few minutes then."

Rationale :

🟤 This response uses therapeutic presence—a core principle in mental health nursing where simply being there supports the client without pressuring them.

🟤 It shows empathy and respect for the client’s current emotional state, especially when they express not wanting to talk.

🟤 Offering to sit silently demonstrates compassionate, nonverbal support, helping build trust and emotional safety.

🟤 This technique is effective for clients experiencing depression, as it honors their boundaries while still communicating care and availability.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 9

Correct Answers:

Obtain client's weight weekly.
Offer the client finger foods for meals.
Encourage the client to take deep breaths when feeling agitated.

Rationale :

Obtain client's weight weekly

🟩 Clients with dementia are at risk for nutritional deficits due to restlessness, poor intake, or wandering.

🟩 Weekly weights help monitor unintended weight loss or changes in nutritional status.

🟩 This is a standard part of care planning for clients with chronic cognitive impairments.

Offer the client finger foods for meals

🟩 Clients with dementia may struggle with utensils or sitting still for meals.

🟩 Finger foods allow easier self-feeding and promote autonomy while supporting caloric intake.

🟩 This also accommodates wandering behaviors commonly seen in dementia.

Encourage the client to take deep breaths when feeling agitated

🟩 Simple relaxation techniques, like deep breathing, can help reduce agitation and anxiety in dementia patients.

🟩 It offers a non-pharmacological coping tool that promotes emotional regulation.

🟩 This approach is safe, effective, and can be reinforced consistently by caregivers.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

Answer 10

Correct Answers:

Providers are required to warn Individuals if the client threatens harm.

Rationale :

🔴 In mental health care, one of the legal exceptions to confidentiality is the duty to warn and protect identifiable individuals if a client makes threats of serious harm.

🔴 This stems from the Tarasoff ruling, which mandates that providers must take reasonable steps—such as warning the potential victim or notifying authorities.

🔴 This is a recognized exception even in situations where confidentiality is usually protected under HIPAA or state law.

🔴 It reflects the ethical obligation to protect life and public safety, even if that means breaching confidentiality.

Distractor Analysis :

Rationale for Incorrect Options to be Available Soon

QLexNursing

1 :
A nurse is caring for a client who escapes anxiety-causing thoughts by ignoring their existence. The nurse should recognize this behavior as which of the following defense mechanisms?

2 :
A nurse is reinforcing discharge teaching with a client who has several new prescriptions for psychotropic medications. The client tells the nurse that she has always had trouble following a medication regimen. Which of the following responses should the nurse make?

3 :
A nurse is caring for a newly admitted female client who has depression and refuses to get out of bed, dress, or participate in group therapy. Which of the following is an appropriate nursing response?

4 :
A nurse is caring for a client who reports a state of Increasing anxiety and the inability to sleep and concentrate. Which of the following is an appropriate response by the nurse?

5 :
A nurse is caring for a client in an acute care mental health unit who was involuntarily admitted for 72 hr after attacking a neighbor. To keep the client in the hospital when the initial time to hold the client expires, which of the following must be determined?

6 :
A nurse observes that a client is sitting alone in her room crying. As the nurse approaches, she states, "I'm feeling really down and don't want to talk to anyone right now." Which of the following responses is appropriate for the nurse?

7 :
A nurse is caring for a client who has a major depressive disorder. Which of the following actions should the nurse take when developing a relationship with the client?

8 :
A nurse observes that a client is sitting alone in her room crying. As the nurse approaches, she states, "I'm feeling really down and don't want to talk to anyone right now." Which of the following responses is appropriate for the nurse?

9 :
A nurse working in a long-term care facility is admitting a client who has dementia.

Answer Options

10 :
A nurse is discussing legal exceptions to client confidentiality with nursing staff. Which of the following statements by a staff member indicates an understanding?

QLexNursing

1 : A nurse is caring for a client who escapes anxiety-causing thoughts by ignoring their existence. The nurse should recognize this behavior as which of the following defense mechanisms?

2 : A nurse is reinforcing discharge teaching with a client who has several new prescriptions for psychotropic medications. The client tells the nurse that she has always had trouble following a medication regimen. Which of the following responses should the nurse make?

3 : A nurse is caring for a newly admitted female client who has depression and refuses to get out of bed, dress, or participate in group therapy. Which of the following is an appropriate nursing response?

4 : A nurse is caring for a client who reports a state of Increasing anxiety and the inability to sleep and concentrate. Which of the following is an appropriate response by the nurse?

5 : A nurse is caring for a client in an acute care mental health unit who was involuntarily admitted for 72 hr after attacking a neighbor. To keep the client in the hospital when the initial time to hold the client expires, which of the following must be determined?

6 : A nurse observes that a client is sitting alone in her room crying. As the nurse approaches, she states, "I'm feeling really down and don't want to talk to anyone right now." Which of the following responses is appropriate for the nurse?

7 : A nurse is caring for a client who has a major depressive disorder. Which of the following actions should the nurse take when developing a relationship with the client?

8 : A nurse observes that a client is sitting alone in her room crying. As the nurse approaches, she states, "I'm feeling really down and don't want to talk to anyone right now." Which of the following responses is appropriate for the nurse?

9 : A nurse working in a long-term care facility is admitting a client who has dementia.

Answer Options

10 : A nurse is discussing legal exceptions to client confidentiality with nursing staff. Which of the following statements by a staff member indicates an understanding?

1 :
A nurse is caring for a client who escapes anxiety-causing thoughts by ignoring their existence. The nurse should recognize this behavior as which of the following defense mechanisms?

2 :
A nurse is reinforcing discharge teaching with a client who has several new prescriptions for psychotropic medications. The client tells the nurse that she has always had trouble following a medication regimen. Which of the following responses should the nurse make?

3 :
A nurse is caring for a newly admitted female client who has depression and refuses to get out of bed, dress, or participate in group therapy. Which of the following is an appropriate nursing response?

4 :
A nurse is caring for a client who reports a state of Increasing anxiety and the inability to sleep and concentrate. Which of the following is an appropriate response by the nurse?

5 :
A nurse is caring for a client in an acute care mental health unit who was involuntarily admitted for 72 hr after attacking a neighbor. To keep the client in the hospital when the initial time to hold the client expires, which of the following must be determined?

6 :
A nurse observes that a client is sitting alone in her room crying. As the nurse approaches, she states, "I'm feeling really down and don't want to talk to anyone right now." Which of the following responses is appropriate for the nurse?

7 :
A nurse is caring for a client who has a major depressive disorder. Which of the following actions should the nurse take when developing a relationship with the client?

8 :
A nurse observes that a client is sitting alone in her room crying. As the nurse approaches, she states, "I'm feeling really down and don't want to talk to anyone right now." Which of the following responses is appropriate for the nurse?

9 :
A nurse working in a long-term care facility is admitting a client who has dementia.

10 :
A nurse is discussing legal exceptions to client confidentiality with nursing staff. Which of the following statements by a staff member indicates an understanding?