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Questions 149

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Question 1 of 5

Mr. S. is a man who has not spoken for years. He is diagnosed as having paranoid schizophrenia. One day, when Ms. J., another client, was standing facing the elevator, the man approached her from behind and reached for her as if to strangle her. What is the most appropriate action for the nurse to take at this time?

Correct Answer: D

Rationale: Getting his attention and calling for help ensures safety for all involved without escalating the situation through physical intervention.

Question 2 of 5

A client with terminal cancer yells at the nurse and says, 'I don't need your help, I can bathe myself.' Which stage of grief is the client most likely experiencing?

Correct Answer: C

Rationale: Yelling and asserting independence reflect anger, a stage of grief where clients may express frustration about their terminal condition.

Question 3 of 5

A young woman was referred to the psychiatrist by her family physician because she is fearful of getting into elevators. During the course of therapy, it was discovered that her initial fear was of men and that it had changed to elevators. Which of the following mechanisms is demonstrated by this change?

Correct Answer: D

Rationale: Displacement involves shifting fear from one object (men) to a less threatening one (elevators), a common defense mechanism.

Question 4 of 5

The adolescent diagnosed with hepatitis is reporting pruritus. Which therapy should the nurse suggest?

Correct Answer: C

Rationale: Cool, moist compresses relieve pruritus in hepatitis by soothing the skin without causing irritation.

Question 5 of 5

A client with cancer states that he has no reason to live anymore. What is the most therapeutic response for the nurse to give at this time?

Correct Answer: A

Rationale: Reflecting the client's statement encourages exploration of his feelings, promoting therapeutic communication without dismissing his despair.

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