Within a few hours of alcohol withdrawal, nurse John should assess the male client for the presence of:
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Solution
Irritability, heightened alertness, jerky movements
Option C: Alcohol is a central nervous system depressant. These symptoms are the body’s neurological adaptation to the withdrawal of alcohol.
Nurse Gerry is aware that the defense mechanism commonly used by clients who are alcoholics is:
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Solution
Denial
Option B: Denial is a method of resolving conflict or escaping unpleasant realities by ignoring their existence.
When planning care for a male client using paranoid ideation, nurse Jasmin should realize the importance of:
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Solution
Providing the client with activities in which success can be achieved
Option B: This will help the client develop self-esteem and reduce the use of paranoid ideation.
Nurse John recognizes that paranoid delusions usually are related to the defense mechanism of:
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Solution
Projection
Option A: Projection is a mechanism in which inner thoughts and feelings are projected onto the environment, seeming to come from outside the self rather than from within.
When being admitted to a mental health facility, a young female adult tells Nurse Mylene that the voices she hears frighten her. Nurse Mylene understands that the client tends to hallucinate more vividly:
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Solution
After going to bed
Option D: Auditory hallucinations are most troublesome when environmental stimuli are diminished and there are few competing distractions.
Nurse Bea notices a female client sitting alone in the corner smiling and talking to herself. Realizing that the client is hallucinating. Nurse Bea should:
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Solution
Leave the client alone until he stops talking
Option B: This provides a stimulus that competes with and reduces hallucination.
One morning, nurse Diane finds a disturbed client curled up in the fetal position in the corner of the dayroom. The most accurate initial evaluation of the behavior would be that the client is:
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Solution
Feeling more anxious today
Option D: The fetal position represents regressed behavior. Regression is a way of responding to overwhelming anxiety.
In recognizing common behaviors exhibited by male client who has a diagnosis of schizophrenia, nurse Josie can anticipate:
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Solution
Withdrawal, regressed behavior, and lack of social skills
Option C: These are the classic behaviors exhibited by clients with a diagnosis of schizophrenia.
Jose who has been hospitalized with schizophrenia tells Nurse Ron, “My heart has stopped and my veins have turned to glass!” Nurse Ron is aware that this is an example of:
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Solution
Somatic delusions
Option A: Somatic delusion is a fixed false belief about one’s body.
When asking the parents about the onset of problems in young client with the diagnosis of schizophrenia, Nurse Linda would expect that they would relate the client’s difficulties began in:
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Solution
Adolescence
Option C: The usual age of onset of schizophrenia is adolescence or early childhood.