A nurse at a mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is using dissociation as a defense mechanism?
A client forgets to buy their partner a birthday gift after a disagreement.
A client who was abused as a child describes the abuse as if it happened to someone else.
A client who is shorter than average is verbally assertive with coworkers.
A client states that they did not get a job promotion because the boss did not like them.
The Correct Answer is B
A. This choice is incorrect because forgetting to buy a gift is not an example of dissociation, but rather a sign of poor memory or lack of attention.
B. This choice is correct because describing the abuse as if it happened to someone else is an example of dissociation, which is a defense mechanism that involves separating oneself from painful or traumatic experiences.
C. This choice is incorrect because being verbally assertive is not an example of dissociation, but rather a personality trait or a coping skill.
D. This choice is incorrect because blaming the boss for not getting a promotion is not an example of dissociation, but rather a sign of external locus of control or rationalization.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Wrapping the cord with petroleum gauze is not recommended. Handling the cord directly can lead to vasospasm and worsen the situation.Choice B reason:
The Trendelenburg position involves placing the mother with her head lower than her pelvis. This position helps to alleviate pressure on the umbilical cord, reducing the risk of cord compression and compromising blood flow to the baby. Additionally, the nurse should also manually elevate the presenting part of the fetus off the umbilical cord to further relieve pressure. These actions can help mitigate the potential complications associated with umbilical cord prolapse until further medical interventions can be implemented.Choice C reason:
Evaluate uterine tone. While evaluating uterine tone is an important part of the overall assessment during labour, it is not the priority action in the case of umbilical cord prolapse. The immediate concern is to relieve pressure on the cord.
Choice D reason:
Option D: Apply fundal pressure. Fundal pressure should not be applied during umbilical cord prolapse as it may push the baby's presenting part further onto the cord, worsening the situation.
Correct Answer is C
Explanation
Choice A reason:
Discourage physical activity during the day is incorrect. Encouraging physical activity is generally beneficial for individuals with dementia. Regular exercise can improve mood, reduce agitation, and enhance overall health. However, the level and type of physical activity should be tailored to the individual's abilities and preferences.
Choice B reason
Use clothing with buttons and zippers is incorrect. Clothing with buttons and zippers can be challenging for individuals with dementia due to fine motor skill impairments and difficulty with dressing. It is often recommended to use clothing with simple closures, such as Velcro or elastic bands, to make dressing easier and more manageable for the individual.
Choice C reason:
Individuals with dementia may experience difficulties with communication, memory, and problem-solving, which can affect their ability to recognize and express the need to use the restroom. As a result, they may be at risk of urinary or bowel incontinence. To address this concern and promote the client's comfort and dignity, establishing a toileting schedule is essential. A consistent routine for bathroom breaks can help prevent accidents and improve the client's overall well-being.
Choice D reason:
Engage the client in activities that increase sensory stimulation is incorrect. While sensory stimulation activities can be enjoyable and engaging for individuals with dementia, it is essential to select activities that are appropriate and not overwhelming. Some individuals with dementia may become overstimulated, which can lead to agitation or distress. Activities should be tailored to the individual's preferences and abilities.
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