During one-to-one session with the nurse, a female client who has been admitted for chronic depression and attempted suicide discloses her experience of sexual promiscuity and prostitution. When the nurse asks the client if she was ever sexually abused as a child, the client says, 'I don't remember, but my mother ran my father off when I was five.' The nurse should recognize that the client may be using which defense mechanism?

Correct Answer: A

Rationale: The correct answer is A: Repression. Repression is a defense mechanism where painful or unacceptable memories are pushed into the unconscious mind to avoid conscious awareness. In this scenario, the client's inability to remember potential childhood sexual abuse could be a result of repressing those memories due to the distress they may cause. The client's response of not remembering but mentioning a significant event from childhood (mother running off father) suggests the possibility of repressed memories. Summary: - Choice B: Denial involves refusing to acknowledge reality, which is not evident in this scenario. - Choice C: Projection involves attributing one's own thoughts or feelings to others, which is not applicable in this context. - Choice D: Rationalization involves creating logical explanations to justify behaviors, which is not demonstrated in the client's response.

Correct Answer: A

Rationale: The correct answer is A: Arts and crafts activity. For a 14-year-old with anorexia, engaging in arts and crafts can provide a therapeutic outlet for self-expression, relaxation, and distraction from negative thoughts about body image or food. It promotes creativity and allows the client to explore emotions in a non-threatening way. Physical exercise (B) may exacerbate the client's condition by reinforcing unhealthy behaviors. Cooking class (C) may trigger anxiety around food. Group therapy (D) can be beneficial, but the client may not be ready to openly discuss their struggles with others. Therefore, the arts and crafts activity is the most suitable choice for this client.

Correct Answer: A

Rationale: The correct answer is A: Notify the healthcare provider. This is the appropriate action because the patient's statement indicates a serious threat to someone's life, requiring immediate intervention by a higher authority for safety measures. Confronting the patient directly may escalate the situation. Administering sedatives is not appropriate as it does not address the threat. Documenting the statement is important but should not be the first and only action taken in such a critical situation.

Correct Answer: A

Rationale: The correct answer is A: Pay close attention and document the nonverbal messages. Nonverbal communication can provide valuable insights into a client's true feelings or concerns. By observing and documenting these cues, the RN can gain a better understanding of the client's needs. This approach allows for a more holistic assessment and helps in providing individualized care. Summary: - B: Asking the client's husband to interpret the discrepancy may not be appropriate as it could breach confidentiality and may not provide accurate information. - C: Ignoring the nonverbal behavior can lead to missing important cues affecting the assessment process. - D: Integrating verbal and nonverbal messages is important, but it starts with paying close attention to and documenting nonverbal messages.

Correct Answer: D

Rationale: The correct answer is D, Lorazepam (Ativan) 2 mg IM. This is because delirium tremens (DTs) is a severe form of alcohol withdrawal that can be life-threatening. Lorazepam is a benzodiazepine that helps to manage the symptoms of alcohol withdrawal, including agitation, hallucinations, and seizures. It works by calming the central nervous system. Prochlorperazine (A) is an antiemetic, not suitable for managing DTs. Hydromorphone (B) is an opioid analgesic, not indicated for alcohol withdrawal. Chlorpromazine (C) is an antipsychotic used for conditions like schizophrenia, not for alcohol withdrawal. In summary, Lorazepam is the appropriate choice for managing DTs due to its effectiveness in calming the central nervous system and managing alcohol withdrawal symptoms.