A female client staggers to day treatment smelling strongly of alcohol. She uses the defense mechanism "rationalization" when approached by the nurse and questioned about her recent alcohol consumption. How is this expressed?

"I have not drunk anything in the last day."

"I can't worry about that problem right now."

"I have to drink to relax to come to day treatment."

"Why does it matter to you if I drink?"

Answer and Explanation

The Correct Answer is C

A)   Incorrect. This statement is a straightforward denial rather than rationalization.
B)   Incorrect. This response is an example of avoidance or distraction, not rationalization.
C)   Correct. Rationalization involves offering logical or reasonable explanations to justify behaviors or actions that might otherwise be unacceptable. In this case, the client is rationalizing her alcohol consumption as a means to relax and cope with the day treatment.

D) Incorrect. This statement reflects a defensive response but is not an example of rationalization.

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Correct Answer is B

Explanation

A) Incorrect. While understanding if the client is experiencing a relapse is important, knowing the timing of the last drink is crucial for assessing the level of intoxication.

B) Correct. Knowing the time of the last drink helps the nurse gauge the current level of alcohol in the client's system, which is crucial in assessing and managing alcohol intoxication.

C) Incorrect. While understanding the duration of the client's problem with alcohol is important, it is not the most immediate concern when the client is showing symptoms of intoxication.
D) Incorrect. Asking about liver problems is relevant but not the first priority when the client is exhibiting signs of alcohol intoxication.

A. A decreased level of consciousness with intermittent periods of hypervigilance. B. A slow onset of confusion and agitation. C. A decrease in the client's output and vital signs. D. The symptoms have lasted longer than a month.

Correct Answer is A

Explanation

A. Delirium is characterized by a fluctuating level of consciousness, which can include periods of hypervigilance.
B. A slow onset of confusion and agitation is more characteristic of dementia rather than delirium.
C. A decrease in output and vital signs may indicate a different condition, but it is not specific to delirium.
D. Delirium is characterized by an acute onset and is typically short-lived, usually lasting days to weeks. Symptoms lasting longer than a month would suggest a different diagnosis.

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A female client staggers to day treatment smelling strongly of alcohol. She uses the defense mechanism "rationalization" when approached by the nurse and questioned about her recent alcohol consumption. How is this expressed?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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