Mental Health

A nurse is interviewing a client who has a history of alcohol use disorder. The client states, "Alcohol is so bad for my body." The nurse should identify that the client is demonstrating which of the following defense mechanisms?

Reaction formation

A nurse is collecting data from a client who has recently been prescribed lithium carbonate. Which of the following findings is the nurse's priority?

Poor motor coordination. The nurse should recognize that this is an advanced manifestation of lithium carbonate toxicity.

A nurse is caring for a client who has anxiety disorder. Which of the following statements by the client should the nurse recognize as demonstrating the defense mechanism of displacement?

"My partner yelled at me, so I made the cat go outdoors."

A nurse on a mental health unit is caring for a group of clients. Which of the following is an example of a client using the defense mechanism of rationalization?

A client who states he drinks alcohol to excess because his marriage is failing.

A nurse is collecting data from a client who is taking lithium to treat bipolar disorder and has a lithium level of 2.2 mEq/L. Which of the following findings should the nurse expect?

Blurry vision. Manifestations of lithium toxicity with levels between 2 and 2.5 mEq/L include blurry vision, ataxia, clonic twitching, severe hypotension, and polyuria.

A nurse is caring for an older adult client who has pnemonia. Which of the following physiological changes associated with aging places the client at a greater risk of pnemonia?

Decreased number of cilia

A nurse is reinforcing discharge teaching about lithium toxicity with a client who has a new prescription for this medication. Which of the following statements by the client indicates an understanding of the teaching?

I can develop lithium toxicity if I experience vomiting or diarrhea.

A nurse caring for a client who has been taking lithium for the past several months. which of the following findings should indicate that the client is experiencing advanced lithium toxicity?

Ataxia The nurse should identify that ataxia, which is the lack of coordination of body movements, is a manifestation of advanced lithium toxicity. Other manifestations can include seizures, blurred vision, severe hypotension, large output of dilute urine, and clonic movements as signs of advanced lithium toxicity. The nurse should notify the provider immediately if these symptoms occur.

A nurse is caring for a client who has alcohol use disorder and claims that her family is "exaggerating the problem." The nurse should identify this behavior as which of the following defense mechanisms?

Denial

A nurse is reinforcing teaching with a client who has a prescription for lithium. Which of the following instructions should the nurse include in the teaching?

Drink 2 L of fluid each day.

A nurse is teaching a client who has a bipolar disorder and a new prescription for lithium. The nurse should identify that which of the following statements by the client indicates an understanding of the teaching?

I am likely to gain weight while taking lithium. The nurse should instruct the client about eating low-calorie diet while taking lithium because this medication can cause weight gain.

A nurse is reinforcing teaching with a client who has a bipolar disorder and a new prescription for lithium. Which of the following directions should the nurse provide?

Increase fluid intake to 2000 mL (67.6 oz) daily.

A nurse is caring for a client who is showing evidence of addiction to a pain medication prescribed for rheumatoid arthritis. When questioned about the usage of the medication, the client states, "it is not an illegal drug." Which of the following defense mechanisms is the client using?

Rationalization

A nurse is speaking with parents who are at a clinic for a 2-week follow up visit after the birth of their second child. They report that their 5-year old daughter has started to wet the bed at night after being toilet trained for 2 years. The nurse should tell the parents that this is expected behavior that illustrates which of the following defense mechanisms?

Regression

A nurse is talking with the parent of an infant during a well-child visit. The parents states, "My 6-year-old son started wetting the bed after we brought his baby sister home. He hasn't done that in over a year." The nurse should recognize that this behavior by the sibling is an indication of which of the following defense mechanisms?

Regression

A nurse is caring for a client who has anxiety disorder. The client states that she forgot her partner's birthday after they had an argument. The nurse recognizes this action as which of the following defense mechanisms?

Repression.

A nurse is caring for a client who just learned that he has a terminal illness. He states, "I'll deal with this after my wife and I take that cruise we've always dreamed about." The nurse should identify that the client is demonstrating which of the following defense mechanisms?

Suppression

A nurse is collecting data from a client prior to the administration of lithium. The client began taking lithium 1 week ago for the treatment of mania. For which of the following findings should the nurse withhold the dose?

Report nausea with frequent episodes of emesis. GI upset is an early indication of lithium toxicity; therefore the nurse should withhold the prescribed dose and obtain a serum lithium level. Check the client for indications of dehydration, which further increases the risk of lithium toxicity.

A nurse is reviewing the medications of a client who has bipolar disorder and a new prescription for lithium. The nurse can safely administer which of the following medications while this client is taking lithium?

Valproic acid Valproic acid and lithium are both indicated for the treatment of bipolar disorder. Therefore, the nurse can administer both of these medications to the client.