After returning to work after a weekend off the nurse gets report that a depressed client has been in bed all weekend. What should the nurse to first? Correct Answer:  Assist the client out of bed and involve in activity.

A client with dementia uses the defense mechanism of confabulation. What is the reasoning? Correct Answer:  To decrease anxiety.

A husband states to the nurse that his wife is not sleeping, buying impulsively, taking last minute trips, and has lost 22 pounds one month. What is an appropriate nursing dx? Correct Answer:  Disturbed thought process.

A nurse is explaining a fire drill routine to a group of clients. A client becomes disruptive and continually interrupts the group. What is the nurse's best response? Correct Answer:  When you interrupt, I cannot explain what to do to the group.

When performing a MSE on a client which assessment intervention would best assist the nurse? Correct Answer:  Ask the client to interpret the proverb a stitch in time saves nine.

A client comes in after being in a car accident and is experiencing alcohol withdrawal, magnesium level of 1.1, cardiac dysthrythmias. What would you give first? Correct Answer:  Magnesium.

A woman is just told of her husband's dx of terminal cancer. What would the nurse offer for the spouse (wife)? Correct Answer:  How would you like to be involved with your husband's care?

A nurse is to remove staples from an abdominal incision, the client is very anxious. What is the most important intervention? Correct Answer:  Attempt to distract the client with general conversation.

A man who was stranded on the roof of his house for two days after a natural disaster, months later ... Correct Answer:  Implement anxiety control strategies.

A man dx with bipolar disorder states, "I don't understand, I believe in God and have not done anything to deserve this". What is the nurse's best response? Correct Answer:  You didn't do anything wrong. You have a chemical imbalance in your brain.

A client becomes upset when the nurse he requests is not assigned to him, what is the nurse's best response? Correct Answer:  Advise the client that nursing assignments are not based on client requests.

A client needs to wash her hands for two hours before able to go on with her morning. She doesn't want to sit on the chairs in the dayroom for fear of getting dirty. What is this mechanism? Correct Answer:  Compulsion.

A client in group is talking about her prostitution, the nurse asks her if she was abused by her parents. She states "my mother ran my father out when I was young". What defense mechanism was used? Correct Answer:  Repression.