20. A client was recently diagnosed with depression related to loss of a spouse. The client describes thinking constantly about the relationship and dreams of reconciliation even though the spouse is deceased. A nurse should document this as:
20. A client was recently diagnosed with depression related to loss of a spouse. The client describes thinking constantly about the relationship and dreams of reconciliation even though the spouse is deceased. A nurse should document this as:
Test-Taking Tip
Note the key word "dreams," which is related to fantasy.
Content Area: Mental Health, Anxiety—Coping Mechanisms; Integrated Process: Communication and Documentation; Cognitive Level: Application; Client Need/Subneed: Psychosocial Integrity/Grief and Loss
.
Answer 1 is incorrect because omnipotence is when a person acts as if more important than others with power over others (e.g., the spouse feels the ability to control the situation through power and persuasion of others). Answer 2 is incorrect because isolation of affect is experienced when the client separates feelings from thoughts or ideas (e.g., feels no emotion when thinking of a sad loss). Answer 3 is correct because the client is "dreaming" and experiencing the ego defense mechanism of fantasy to cope with the anxiety associated with the loss of a spouse. Fantasy is a break from reality. Answer 4 is incorrect because regression occurs when the client exhibits behaviors from an earlier stage of development (e.g., an adult who behaves in an immature manner, such as clutching a stuffed animal, when dealing with stressful situations such as loss).
