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

Choice A rationale:

Activating the fire alarm system is the second action the nurse should take after rescuing the individuals in the area.

Choice B rationale:

Obtaining and using a fire extinguisher should only be attempted by personnel trained to do so. Using a fire extinguisher incorrectly can escalate the fire or cause harm to individuals in the vicinity. The priority is to evacuate and let trained personnel handle the fire.

Choice C rationale:

Evacuating clients from the area is an essential and immediate step. Evacuation ensures the safety of everyone in the area, preventing potential harm due to smoke inhalation or fire spread.

Choice D rationale:

Closing the doors and windows on the unit can help contain the fire and prevent its spread. However, this action should be taken after activating the fire alarm system and initiating the evacuation process. Closing doors and windows can buy some time and limit the fire's oxygen supply, but it should not delay the evacuation procedure.

A. Clean the mouthpiece with warm water every 2 weeks B. Wait 10 seconds between inhalations C. Take a quick inhalation when pressing the dispenser D. Take the medication 15 min before playing sports

Correct Answer is D

Explanation

Take the medication 15 min before playing sports.

A. Clean the mouthpiece with warm water every 2 weeks. This is incorrect because the mouthpiece should be cleaned with warm water at least once a week, or more often if used frequently, to prevent bacterial growth and contamination.
B. Wait 10 seconds between inhalations. This is incorrect because the recommended time interval between inhalations is 1 minute, not 10 seconds, to allow adequate absorption of the medication and prevent overdose or side effects.
C. Take a quick inhalation when pressing the dispenser. This is incorrect because a quick inhalation can cause poor coordination of hand-mouth movement and result in less medication reaching the lungs. The nurse should instruct the child to take a slow, deep inhalation when pressing the dispenser, hold their breath for 10 seconds, and exhale slowly.
D. Take the medication 15 min before playing sports. This is correct because albuterol is a short-acting bronchodilator that can prevent exercise-induced bronchospasm. The nurse should teach the child to take the medication before engaging in physical activity that can trigger asthma symptoms, such as sports, cold weather, or allergens.

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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 charge nurse observes smoke coming from a trash receptacle in the unit's waiting room. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse is providing teaching to a school-age child who has asthma about using an albuterol metered-dose inhaler. Which of the following instructions should the nurse include?

Correct Answer is D

Explanation

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