A nurse in an urgent care facility is caring for a client who has traumatic injuries following an assault. The client sits quietly and calmly tells the nurse, "I'm fine." The nurse should recognize the client's behavior as which of the following reactions?

Projection

Displacement

Denial

Undoing

Answer and Explanation

The Correct Answer is C

The client's behavior of stating "I'm fine" despite having traumatic injuries is an example of denial, a coping mechanism that involves denying that a problem or issue exists. Projection involves attributing one's own feelings to another person, displacement involves redirecting one's emotions onto a less threatening target, and undoing involves seeking to undo or forget past actions.

Choice A, projection, would involve the client attributing their own feelings to others.

Choice B, displacement, would involve the client redirecting their emotions onto someone or something else. Finally,

choice D, undoing, would involve the client attempting to forget or undo past actions.

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Correct Answer is B

Explanation

Answer: B. Cloudy dialysate outflow.

Rationale:

A) Blood-tinged dialysate outflow.
While blood-tinged outflow can be concerning, it may not always indicate a severe complication, especially if it is minimal. It should be monitored and documented, but it does not require immediate reporting unless it becomes excessive.

B) Cloudy dialysate outflow.
This finding is significant and warrants immediate reporting to the provider as it may indicate peritonitis, an infection of the peritoneal cavity. Prompt intervention is critical to address potential complications associated with dialysis.

C) Dialysate leakage during inflow.
Dialysate leakage can occur and might be due to improper catheter placement or other issues. While it requires attention, it is not as urgent as cloudy dialysate outflow and can typically be managed without immediate escalation.

D) Report of discomfort during dialysate inflow.
Mild discomfort during inflow can be common, especially in the initial stages of peritoneal dialysis. It should be noted and assessed, but it does not necessarily require immediate reporting unless it is severe or persistent.

A. "You should stop because you need to. You are destroying your health." B. "Do you have any idea why you do this?" C. "I'm proud of you for recognizing that this behavior is not normal." D. "It seems like you are feeling helpless about this behavior."

Correct Answer is D

Explanation

A therapeutic response to the client's statement would be to acknowledge that the client feels helpless about the behavior. The nurse should avoid judging or criticizing the client and instead focus on offering support and empathy.

Options A and B are not therapeutic because they are confrontational and may make the client defensive. Option C is a well-intentioned but empty statement that does not offer any practical support or guidance to the client.

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A nurse in an urgent care facility is caring for a client who has traumatic injuries following an assault. The client sits quietly and calmly tells the nurse, "I'm fine." The nurse should recognize the client's behavior as which of the following reactions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient who is undergoing initial peritoneal dialysis. Which of the following should the nurse report immediately to the provider?

Correct Answer is B

Explanation

A nurse is caring for a 20-year-old college student who has a 2-year history of bulimia nervosa. She tells the nurse, "I know my eating binges and vomiting are not normal, but I cannot do anything about them." Which of the following is a therapeutic response by the nurse?

Correct Answer is D

Explanation

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