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 D

Explanation

Choice A rationale:

The statement, "I will take the medication in the morning," indicates lack of understanding. Metformin is usually taken with large meals, and taking it in the morning is not the best timing.

Choice B rationale:

The statement, "I will expect to gain weight," is incorrect. Weight gain is not an expected side effect of metformin. In fact, metformin is often associated with weight loss or weight maintenance, especially in individuals with diabetes, as it helps improve insulin sensitivity and glucose metabolism.

Choice C rationale:

The statement, "I will take the medication on an empty stomach," is incorrect for extended-release metformin tablets. Unlike immediate-release metformin, extended-release tablets should be taken with meals to reduce the risk of gastrointestinal side effects.

Choice D rationale:

The statement, "I will avoid crushing this medication," is correct. Metformin extended-release tablets should never be crushed or broken, as it can affect the way the medication is released into the body. Crushing or breaking the tablet can lead to a sudden release of a large amount of metformin, potentially causing an overdose.

A. The LPN and AP lower the side rails before lifting the client up in bed. B. Prior to lifting the client, the LPN and AP raise the bed to waist level. C. The LPN and the AP grasp the client under his arms to lift him up in bed. D. The LPN and the AP ask the client to flex his knees and push his heels into the bed as they lift.

Correct Answer is C

Explanation

- A. The LPN and AP lower the side rails before lifting the client up in bed is incorrect. This is a safe practice that prevents injury to the client and staff by providing more space for movement and reducing the risk of falling.

- B. Prior to lifting the client, the LPN and AP raise the bed to waist level is incorrect. This is a safe practice that prevents injury to the client and staff by reducing the need for bending and lifting.

- C. The LPN and the AP grasp the client under his arms to lift him up in bed is correct. This is an unsafe practice that can cause injury to the client's shoulders, neck, and axillae by applying excessive pressure and friction. The LPN and AP should use a draw sheet or a mechanical lift device to move the client up in bed.

- D. The LPN and the AP ask the client to flex his knees and push his heels into the bed as they lift is incorrect. This is a safe practice that encourages active participation from the client and reduces the workload for the staff by using leverage.

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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 teaching a client who has a new prescription for metformin extended-release tablets. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

An RN is observing a licensed practical nurse (LPN) and an assistive personnel (AP) move a client up in bed. For which of the following situations should the nurse intervene?

Correct Answer is C

Explanation

A nurse is preparing to initiate IV access for an older adult client. Which of the following sites should the nurse select when initiating the IV for this client?

A nurse is planning to reinforce teaching with a preschooler who is about to undergo an incision and drainage for cellulitis on the left arm. Which of the following techniques should the nurse use?

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