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 A
Explanation
A is correct because delegating non-nursing tasks to ancillary staff allows nurses to focus on more complex and skilled tasks that require their expertise and judgment, thus improving efficiency and quality of care.
B is incorrect because stocking client rooms with extra supplies increases waste and costs, as well as clutter and infection risk.
C is incorrect because assigning dedicated equipment to each client's room reduces availability and accessibility of equipment for other clients, as well as increases maintenance and cleaning costs.
D is incorrect because changing continuous IV infusion tubing every 24 hr is not cost-effective, as it does not reduce the risk of infection significantly compared to changing it every 72 hr, according to current evidence-based practice guidelines.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
The client is at risk for experiencing electrolyte imbalance due to the vomiting. Persistent vomiting during pregnancy, especially with significant weight loss, can lead to electrolyte imbalances such as hypokalemia, hyponatremia, or metabolic alkalosis. This can result from the body's inability to retain essential minerals and fluids. The client’s reported diet of minimal food intake, primarily consisting of toast and pretzels, indicates inadequate nutrition and potential for further exacerbation of these imbalances.
The significant weight loss of 6.8 kg (15 lb) within a month and continuous nausea and vomiting are concerning symptoms that warrant immediate medical evaluation. The nurse’s advice to seek a provider’s assessment underscores the need for timely intervention to address potential complications, ensure maternal and fetal health, and possibly prescribe antiemetic medications or other treatments to manage symptoms.
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