A client who abuses alcohol and cocaine tells a nurse that he only uses substances because of his stressful marriage and difficult job. Which defense mechanisms is this client using?

Correct Answer: C

Rationale: The correct answer is C: Rationalization. Rationalization is a defense mechanism where an individual justifies their undesirable behavior with seemingly logical reasons. In this case, the client is attributing their substance abuse to external stressors (marriage and job) to make it seem more acceptable. Displacement (A) involves redirecting emotions to a substitute target, projection (B) is attributing one's own thoughts or feelings to others, and sublimation (D) is channeling unacceptable impulses into socially acceptable activities. In this scenario, the client is rationalizing their substance abuse, making choice C the most appropriate.

Correct Answer: C

Rationale: The correct answer is C: Report incomplete bladder emptying. Elderly clients with benign prostatic hypertrophy are at risk for urinary retention, which can be exacerbated by psychotropic drugs. Reporting incomplete bladder emptying is crucial to prevent urinary retention and potential complications. Adding fiber to the diet (choice A) and exercising regularly (choice B) are important for overall health but not directly related to the potential side effects of the drug. Taking the prescribed dose at bedtime (choice D) may be important for drug effectiveness but doesn't address the specific risk of urinary retention in this client population.

Correct Answer: C

Rationale: The correct answer is C: Remain calm and talk quietly to the client. This approach is appropriate as it helps to de-escalate the situation and maintain a therapeutic environment. By remaining calm and speaking quietly, the nurse can help reduce the client's agitation and build trust. It also shows respect for the client's feelings and dignity. Choice A is incorrect because telling the client's family to get dressed is not addressing the client's agitation behavior. Choice B is inappropriate as restraining the client should only be considered as a last resort for safety reasons. Choice D is not the best initial intervention as sedation should not be the first response to behavioral issues in clients with Alzheimer's disease.

Correct Answer: B

Rationale: The correct answer is B because it focuses on how the client's actions will impact their family relationships, indicating a deeper understanding of the client's situation. Choice A is incorrect as it assumes motivation. Choice C is incorrect as it merely suggests a task without addressing the client's implications. Choice D is incorrect as it imposes a specific recommendation without considering the client's individual circumstances.

Correct Answer: D

Rationale: The correct answer is D because it encourages the client to provide specific details about the situation, leading to a clearer understanding of what happened. By asking the client to describe the events during visiting hours, the nurse can gather essential information to assess the situation accurately. This open-ended question allows the client to express their thoughts and feelings freely, enabling the nurse to identify any potential issues or concerns. Choices A, B, and C are incorrect because they do not focus on gathering specific information about the situation that occurred. Option A assumes the behavior is recurring without knowing the details. Option B shifts the focus to the client's role rather than the husband's behavior. Option C asks for speculation on the husband's behavior without allowing the client to provide actual details. These options may lead to assumptions and incomplete assessment of the situation.