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 C

Explanation

- A. Incorrect. The nurse should assess the client's IV site every hour to prevent infection and phlebitis.

- B. Incorrect. The nurse should check the client's WBC count every day to monitor for signs of infection or bone marrow suppression.

- C. Correct. The nurse should monitor the client's mouth every 8 hr for signs of oral candidiasis, which is a common fungal infection in immunosuppressed clients.\

- D. Incorrect. The nurse should change the client's IV tubing every 24 hr to reduce the risk of bacterial contamination.

Correct Answer is ["13"]

Explanation

gtt/min = (mL/hr x gtt/mL) / 60

gtt/min = (50 x 15) / 60 gtt/min = 750 / 60 gtt/min = 12.5 Rounding to the nearest whole number, the answer is 13.

Therefore, the nurse should set the manual IV infusion to deliver 13 gtt/min.

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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 has immunosuppression and a continuous IV infusion. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

Correct Answer is ["13"]

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?

A nurse is caring for a client who has deep-vein thrombosis and a new prescription for antiembolitic stockings. Which of the following actions should the nurse take?

A nurse is planning to delegate client care tasks to an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP?

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