Question

During a group therapy session, a nurse notes several clients using multiple defense mechanisms. Which of the following client statements demonstrates the maladaptive use of regression?

Answer 1

Correct Answers:

"l don't care about work anymore since I was not given a promotion"

Rationale :

🟣 Regression involves reverting to earlier stages of development or immature behaviors in response to stress or conflict.

🟣 The client’s statement of no longer caring about work reflects a child-like withdrawal after experiencing disappointment.

🟣 Rather than managing the situation adaptively, the client exhibits a passive and avoidant reaction, which is maladaptive.

🟣 Regression can manifest as emotional withdrawal, temper tantrums, or sulking when faced with frustration.

🟣 This behavior may be unconscious and serves as a defense mechanism to avoid psychological discomfort.

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Answer 2

Correct Answers:

Talk the client through tasks one step at a time.

Rationale :

🔵 Clients with Alzheimer's disease experience progressive cognitive decline, making complex tasks difficult.

🔵 Providing step-by-step instructions supports memory deficits and improves the client’s ability to complete tasks successfully.

🔵 This approach reduces frustration and confusion, promoting functional independence for as long as possible.

🔵 It also supports the development of routine and familiarity, which are crucial in dementia care.

🔵 Nursing care should be consistent, simple, and paced according to the client's level of functioning.

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Answer 3

Correct Answers:

Decrease anxiety to a tolerable level.

Rationale :

🟡 In Obsessive-Compulsive Disorder (OCD), compulsive behaviors like cleaning are used to relieve intense anxiety.

🟡 The act of picking up after others is not about control or manipulation but rather serves to neutralize distressing thoughts.

🟡 Repetitive behaviors are ritualistic and function as a form of emotional regulation.

🟡 This coping mechanism becomes reinforced as it provides short-term relief from discomfort.

🟡 Recognizing this helps nurses plan interventions such as CBT and exposure therapy.

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Answer 4

Correct Answers:

Increasing feelings of anger.

Rationale :

🔴 Clients with Post-Traumatic Stress Disorder (PTSD) often display heightened irritability and anger outbursts.

🔴 This is a result of hyperarousal symptoms, part of the body’s exaggerated stress response.

🔴 Traumatic events can alter mood regulation and cause individuals to feel on edge or easily agitated.

🔴 Increased anger may be accompanied by sleep disturbances, hypervigilance, and difficulty concentrating.

🔴 Anger in PTSD is not always situational—it may occur suddenly or persistently without clear triggers.

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Answer 5

Correct Answers:

Affective flattening

Rationale :

🟢 Negative symptoms of schizophrenia involve a loss or reduction in normal emotional or behavioral function.

🟢 Affective flattening refers to diminished emotional expression, such as lack of facial expression or monotone speech.

🟢 Unlike hallucinations or delusions, negative symptoms can impair social functioning more chronically.

🟢 These symptoms are less responsive to antipsychotic medications and contribute to long-term disability.

🟢 Early identification supports better functional planning and therapeutic communication strategies.

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Answer 6

Correct Answers:

A needleless syringe and a doll

Rationale :

🟤 Therapeutic play using medical tools allows young children to express and process feelings related to procedures.

🟤 The needleless syringe and doll help the child gain a sense of mastery and familiarity with injections.

🟤 This type of play is especially beneficial for preschool-aged children, who respond to visual and tactile experiences.

🟤 It encourages emotional processing and coping skill development through imitation and repetition.

🟤 Nurses should select play materials that mirror the child's experience to reduce procedural anxiety.

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Answer 7

Correct Answers:

"You’ve been feeling that your life has no meaning."

Rationale :

🟠 This response uses therapeutic communication, specifically the technique of reflection and restating feelings.

🟠 It validates the client's emotions without judgment or offering false reassurance.

🟠 Such responses help the client feel heard and understood, fostering trust and openness.

🟠 It also encourages the client to explore their thoughts further and facilitates insight.

🟠 Nurses must avoid minimizing or challenging suicidal ideation and instead provide a supportive environment.

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Answer 8

Correct Answers:

"We do every day. Why are you so angry with me this morning?"

Rationale :

🧡 This response uses therapeutic confrontation, helping the client explore emotional triggers and foster insight.

🧡 It maintains structure and routine, which are essential when working with clients who have Borderline Personality Disorder (BPD).

🧡 The nurse does not retaliate or withdraw but rather gently confronts the emotional reaction.

🧡 This encourages emotional regulation and awareness without escalating the situation.

🧡 Consistent boundaries and validation are critical in managing interpersonal sensitivity in BPD.

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Answer 9

Correct Answers:

Experiencing diarrhea

Rationale :

🔵 Dehydration from diarrhea can lead to increased serum lithium levels, risking lithium toxicity.

🔵 Lithium has a narrow therapeutic index, and any fluid or electrolyte imbalance can disrupt excretion.

🔵 The kidneys excrete lithium, and reduced fluid volume impairs clearance, causing accumulation.

🔵 Signs of toxicity include nausea, tremors, confusion, and ataxia.

🔵 Nurses should educate clients to maintain hydration and report gastrointestinal symptoms promptly.

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Answer 10

Correct Answers:

"You must be very upset about something."

Rationale :

🟣 This response uses empathy and validation, helping the client identify and process their feelings.

🟣 Clients in a manic state may experience heightened emotional sensitivity and impulsivity.

🟣 Offering a calm, nonjudgmental response promotes emotional regulation and therapeutic rapport.

🟣 It avoids confrontation and redirects the client’s focus toward effective communication.

🟣 Nurses must remain neutral and supportive, especially during nighttime agitation in bipolar clients.

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QLexNursing

1 :
During a group therapy session, a nurse notes several clients using multiple defense mechanisms. Which of the following client statements demonstrates the maladaptive use of regression?

2 :
A nurse on a long-term care unit is creating a plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan?

3 :
A nurse is caring for a client who has been diagnosed with obsessive compulsive disorder (OCD) and is constantly picking up after others in the day room. The nurse should recognize that the client uses this behavior to do which of the following?

4 :
A nurse is assessing a client who has posttraumatic stress disorder (PTSD) following a sexual assault. Which of the following is an expected finding?

5 :
A nurse is performing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse identify as a negative symptom?

6 :
A nurse is caring for a 4-year-old child who has a new diagnosis of diabetes mellitus and is distressed after an insulin injection. Which of the following play activities should the nurse recognize is therapeutic in helping the child deal with the injection?

7 :
A nurse is caring for a client who has major depressive disorder and attempted suicide. The client tells the nurse, "l should have died because I am totally worthless." Which of the following responses should the nurse make?

9 :
A nurse is caring for a client who has been hospitalized for treatment of bipolar disorder and will be discharged with a prescription for lithium. The nurse's discharge teaching should include information cautioning against which of the following factors that may cause lithium toxicity?

10 :
A nurse who works in a psychiatric unit is caring for a client who has bipolar disorder. The client comes to the nurse’s station at 0300 demanding that the nurse call the provider immediately. Which of the following responses by the nurse is appropriate?

QLexNursing

1 : During a group therapy session, a nurse notes several clients using multiple defense mechanisms. Which of the following client statements demonstrates the maladaptive use of regression?

2 : A nurse on a long-term care unit is creating a plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan?

3 : A nurse is caring for a client who has been diagnosed with obsessive compulsive disorder (OCD) and is constantly picking up after others in the day room. The nurse should recognize that the client uses this behavior to do which of the following?

4 : A nurse is assessing a client who has posttraumatic stress disorder (PTSD) following a sexual assault. Which of the following is an expected finding?

5 : A nurse is performing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse identify as a negative symptom?

6 : A nurse is caring for a 4-year-old child who has a new diagnosis of diabetes mellitus and is distressed after an insulin injection. Which of the following play activities should the nurse recognize is therapeutic in helping the child deal with the injection?

7 : A nurse is caring for a client who has major depressive disorder and attempted suicide. The client tells the nurse, "l should have died because I am totally worthless." Which of the following responses should the nurse make?

9 : A nurse is caring for a client who has been hospitalized for treatment of bipolar disorder and will be discharged with a prescription for lithium. The nurse's discharge teaching should include information cautioning against which of the following factors that may cause lithium toxicity?

10 : A nurse who works in a psychiatric unit is caring for a client who has bipolar disorder. The client comes to the nurse’s station at 0300 demanding that the nurse call the provider immediately. Which of the following responses by the nurse is appropriate?

1 :
During a group therapy session, a nurse notes several clients using multiple defense mechanisms. Which of the following client statements demonstrates the maladaptive use of regression?

2 :
A nurse on a long-term care unit is creating a plan of care for a client who has Alzheimer's disease. Which of the following interventions should the nurse include in the plan?

3 :
A nurse is caring for a client who has been diagnosed with obsessive compulsive disorder (OCD) and is constantly picking up after others in the day room. The nurse should recognize that the client uses this behavior to do which of the following?

4 :
A nurse is assessing a client who has posttraumatic stress disorder (PTSD) following a sexual assault. Which of the following is an expected finding?

5 :
A nurse is performing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse identify as a negative symptom?

6 :
A nurse is caring for a 4-year-old child who has a new diagnosis of diabetes mellitus and is distressed after an insulin injection. Which of the following play activities should the nurse recognize is therapeutic in helping the child deal with the injection?

7 :
A nurse is caring for a client who has major depressive disorder and attempted suicide. The client tells the nurse, "l should have died because I am totally worthless." Which of the following responses should the nurse make?

9 :
A nurse is caring for a client who has been hospitalized for treatment of bipolar disorder and will be discharged with a prescription for lithium. The nurse's discharge teaching should include information cautioning against which of the following factors that may cause lithium toxicity?

10 :
A nurse who works in a psychiatric unit is caring for a client who has bipolar disorder. The client comes to the nurse’s station at 0300 demanding that the nurse call the provider immediately. Which of the following responses by the nurse is appropriate?