A charge nurse is educating a newly licensed nurse about various defense mechanisms. Which of the following examples should the charge nurse provide when discussing rationalization?

A client who has stomach pain before presenting a project to his coworkers.

A client whose partner died 5 years ago still talks about him in the present tense.

A client who states she will worry about her grades after she finishes planning a party.

A client who states she did not get a promotion because her boss dislikes her.

Answer and Explanation

The Correct Answer is D

Rationalization is a defense mechanism that involves making excuses or justifying one's behavior or failures. The client who blames their boss for not getting a promotion is using rationalization to avoid accepting responsibility or acknowledging their shortcomings. The other examples are not related to rationalization, but to other defense mechanisms, such as somatization, denial, and procrastination.

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Correct Answer is C

Explanation

A client who has moderate-stage Alzheimer's disease may experience confusion, memory loss, wandering, agitation, and impaired judgment. Placing this client closest to the nurse's station can facilitate close observation and intervention, as well as reduce environmental stimuli that may trigger anxiety or disorientation.

A. The client has a flat affect. B. The client's manifestations developed suddenly. C. The client's speech is slow and repetitious. D. The client is unable to recognize objects.

Correct Answer is B

Explanation

Delirium is an acute confusional state that can have various causes, such as infection, medication, or metabolic imbalance. It is characterized by a sudden onset of altered mental status, fluctuating levels of consciousness, disorientation, and perceptual disturbances.

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A charge nurse is educating a newly licensed nurse about various defense mechanisms. Which of the following examples should the charge nurse provide when discussing rationalization?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse is making room assignments for new client admissions. Which of the following clients should the nurse place closest to the nurse's station?

Correct Answer is C

Explanation

A nurse is assessing a client who is restless and constantly mutters to himself. Which of the following findings should lead the nurse to suspect delirium?

Correct Answer is B

Explanation

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A nurse is assisting with obtaining informed consent for a client who has been declared legally incompetent. Which of the following actions should the nurse take?

A nurse is caring for a client whose partner died 6 months ago. Which of the following findings is the nurse's priority?

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