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.

Answer and Explanation

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.

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Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"B"}

Explanation

Completed Sentence: The client is at risk for developing hemorrhagic stroke due to autonomic dysreflexia. Rationale: Hemorrhagic Stroke: This is a serious condition that can occur as a complication of a high spinal cord injury. Due to the injury at T4, the client may be at risk for blood pressure dysregulation, which can lead to a hemorrhagic stroke. Autonomic Dysreflexia: This condition is characterized by a sudden increase in blood pressure, often triggered by stimuli such as a full bladder, bowel distention, or pain. In this client, the headache rated 9/10, diaphoresis, flushed skin, agitation, labored breathing, and elevated blood pressure (185/105 mm Hg) are indicative of autonomic dysreflexia.

A. The child exhibits discomfort while walking. B. The child has thin extremities. C. The child has bruises on the upper back D. The child is wearing a stained shirt.

Correct Answer is A

Explanation

A. This is correct because discomfort while walking can indicate genital trauma or infection, which are possible signs of sexual abuse.
B. This is incorrect because thin extremities can be caused by many factors, such as malnutrition, genetic disorders, or chronic diseases, that are not necessarily related to sexual abuse.
C. This is incorrect because bruises on the upper back can result from accidental injuries, such as falls or bumps, or from physical abuse, such as hitting or kicking, but not specifically from sexual abuse.
D. This is incorrect because a stained shirt can be due to poor hygiene, food spills, or environmental factors, but not necessarily from sexual abuse.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 3 days postoperative following a T4 spinal cord injury. Exhibits Select 1 condition and 1 client finding to fill in each blank in the following sentence.</p> The client is at risk for developing dropdown due to dropdown .

Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"B"}

Explanation

A nurse in the emergency department is assessing a preschooler who has a facial laceration. The nurse should identify which of the following findings as a potential indication of child sexual abuse?

Correct Answer is A

Explanation

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