Question 1 pts
The mother of a 3-year-old child tells the nurse that her child hit
her doll after the mother scolded her for picking the neighbors’
flowers. Which defense mechanism used by the child does the
nurse identify in the mother’s report?
Projection
Sublimation
Co
orrrec
ct! Displacement
Identification
Rationale: The defense mechanism of displacement
involves the discharge of intense feelings for one person
onto a substitute person or object that is less threatening
to satisfy an impulse. Projection involves attributing an
attitude, behavior, or impulse, such as that which occurs in
blaming or scapegoating, to someone else. Sublimation is
the act of rechanneling an impulse into a more socially
acceptable object. Identification involves modeling
behavior after someone else's.
Test-Taking Strategy: Use the process of elimination and
knowledge regarding the subject, defense mechanisms.
Focusing on the data in the question and the child’s
behavior will direct you to the correct option. Review these
defense mechanisms if you had difficulty with this
question.
Cognitive Ability: Understanding
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Mental Health
Question 2 pts
, A client says to the nurse, “I’ve been following my diet and taking
my medication. What else do you want to talk about today?”
Which response would be most helpful during the working phase
of the therapeutic alliance?
“Sounds fine to me. Let’s meet again in 6 months.”
“I don’t believe that you have been following your diet because
you haven’t lost any weight.”
“Well, you’ve talked about diet in your terms, but perhaps I
should test you on specific things.”
Co
orrrec
ct!
“Some people have added exercise to diet and medication
therapy and gotten positive results. Do you think that this would
work for you?”
Rationale: Although suggestion or overt giving of advice is
sometimes nontherapeutic, these strategies are
therapeutic when used in the working phase, because in
this situation they will increase the client’s perception of all
available options in the treatment plan. Answering
“Sounds fine to me. Let’s meet again in 6 months” stops
the communication process. Stating to the client that he or
she has not lost any weight implies disbelief and does not
explore the reasons for the client’s failure to lose weight.
“Testing” challenges the client and is nontherapeutic.
Test-Taking Strategy: Use the process of elimination and
therapeutic communication techniques. Noting the words
“working phase” in the question will direct you to the
correct option. Review therapeutic communication
techniques if you had difficulty with this question.
Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
, Question 3 pts
As the nurse prepares to interview a client being admitted to the
mental health unit, the client says, “I asked my family to bring me
in here to talk to someone, but now I don’t know where to begin.”
Which response by the nurse would be most helpful?
“Why not just start talking and see where it takes you?”
“If I were you, I’d begin with what you were doing this morning.”
Co
orrrec
ct!
“Perhaps you can start by sharing some of your most recent
concerns.”
“Don’t worry. Everyone who comes in here for the first time feels
reluctant to talk.”
, Rationale: The intake interview is usually the first contact
with the client. It is intended to establish rapport, to help
the nurse understand the client’s current problem and
level of functioning, and to help the nurse formulate a
nursing care plan. The clinician usually allows the client to
set the pace of the interview and uses open-ended
questions to elicit a comprehensive diagnostic picture of
the client’s problems and level of coping. Sharing
concerns is a good place to start the conversation
because it will allow the client to express feelings. The
response “Why not just start talking and see where it takes
you?” is too general and does not provide the client with a
focus on self. Telling the client not to worry is
nontherapeutic and avoids addressing the client’s
concerns.
Test-Taking Strategy: Use your knowledge of therapeutic
communication techniques. Focusing on the client’s
feelings will direct you to the correct option. Review
therapeutic communication techniques if you had difficulty
with this question.
Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
Question 4 pts
During a mental health intake interview, a young adult client who
lives with his family rent free says, “I’m tired of not being able to
offer my friends a beer just because my folks don’t believe in
taking a drink socially.” Which nursing response would be
therapeutic?
“Well, I guess you could move out and live on your own if you
wanted to.”
Co
orrrec
ct!
“It seems that your parents expect you to follow their rules when
you live under their roof.”
The mother of a 3-year-old child tells the nurse that her child hit
her doll after the mother scolded her for picking the neighbors’
flowers. Which defense mechanism used by the child does the
nurse identify in the mother’s report?
Projection
Sublimation
Co
orrrec
ct! Displacement
Identification
Rationale: The defense mechanism of displacement
involves the discharge of intense feelings for one person
onto a substitute person or object that is less threatening
to satisfy an impulse. Projection involves attributing an
attitude, behavior, or impulse, such as that which occurs in
blaming or scapegoating, to someone else. Sublimation is
the act of rechanneling an impulse into a more socially
acceptable object. Identification involves modeling
behavior after someone else's.
Test-Taking Strategy: Use the process of elimination and
knowledge regarding the subject, defense mechanisms.
Focusing on the data in the question and the child’s
behavior will direct you to the correct option. Review these
defense mechanisms if you had difficulty with this
question.
Cognitive Ability: Understanding
Client Needs: Psychosocial Integrity
Integrated Process: Nursing Process/Data Collection
Content Area: Mental Health
Question 2 pts
, A client says to the nurse, “I’ve been following my diet and taking
my medication. What else do you want to talk about today?”
Which response would be most helpful during the working phase
of the therapeutic alliance?
“Sounds fine to me. Let’s meet again in 6 months.”
“I don’t believe that you have been following your diet because
you haven’t lost any weight.”
“Well, you’ve talked about diet in your terms, but perhaps I
should test you on specific things.”
Co
orrrec
ct!
“Some people have added exercise to diet and medication
therapy and gotten positive results. Do you think that this would
work for you?”
Rationale: Although suggestion or overt giving of advice is
sometimes nontherapeutic, these strategies are
therapeutic when used in the working phase, because in
this situation they will increase the client’s perception of all
available options in the treatment plan. Answering
“Sounds fine to me. Let’s meet again in 6 months” stops
the communication process. Stating to the client that he or
she has not lost any weight implies disbelief and does not
explore the reasons for the client’s failure to lose weight.
“Testing” challenges the client and is nontherapeutic.
Test-Taking Strategy: Use the process of elimination and
therapeutic communication techniques. Noting the words
“working phase” in the question will direct you to the
correct option. Review therapeutic communication
techniques if you had difficulty with this question.
Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
, Question 3 pts
As the nurse prepares to interview a client being admitted to the
mental health unit, the client says, “I asked my family to bring me
in here to talk to someone, but now I don’t know where to begin.”
Which response by the nurse would be most helpful?
“Why not just start talking and see where it takes you?”
“If I were you, I’d begin with what you were doing this morning.”
Co
orrrec
ct!
“Perhaps you can start by sharing some of your most recent
concerns.”
“Don’t worry. Everyone who comes in here for the first time feels
reluctant to talk.”
, Rationale: The intake interview is usually the first contact
with the client. It is intended to establish rapport, to help
the nurse understand the client’s current problem and
level of functioning, and to help the nurse formulate a
nursing care plan. The clinician usually allows the client to
set the pace of the interview and uses open-ended
questions to elicit a comprehensive diagnostic picture of
the client’s problems and level of coping. Sharing
concerns is a good place to start the conversation
because it will allow the client to express feelings. The
response “Why not just start talking and see where it takes
you?” is too general and does not provide the client with a
focus on self. Telling the client not to worry is
nontherapeutic and avoids addressing the client’s
concerns.
Test-Taking Strategy: Use your knowledge of therapeutic
communication techniques. Focusing on the client’s
feelings will direct you to the correct option. Review
therapeutic communication techniques if you had difficulty
with this question.
Cognitive Ability: Applying
Client Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Content Area: Mental Health
Question 4 pts
During a mental health intake interview, a young adult client who
lives with his family rent free says, “I’m tired of not being able to
offer my friends a beer just because my folks don’t believe in
taking a drink socially.” Which nursing response would be
therapeutic?
“Well, I guess you could move out and live on your own if you
wanted to.”
Co
orrrec
ct!
“It seems that your parents expect you to follow their rules when
you live under their roof.”
