A nurse is assessing the coping strategies of a client who has recently retired.
Which of the following statements by the client indicates that the client is using compensation as a defense mechanism?
"Since I retired, I have entered many gardening competitions."
"I'm so glad I've retired because the work was making me sick and depressed."
"I had to retire because my boss didn't like me."
"There were lay-offs at my company, so I journaled about what I accomplished during my career." .
The Correct Answer is A
Choice A rationale:
"Since I retired, I have entered many gardening competitions." This statement indicates compensation as a defense mechanism. Compensation involves emphasizing personal strengths in one area to shift focus from failure or weakness in another. In this case, the client is finding fulfillment and recognition in gardening competitions after retiring, compensating for the loss of work-related identity.
Choice B rationale:
Expressing relief about retirement due to negative work experiences doesn’t necessarily indicate compensation. It could be a coping mechanism, but it doesn't align with the compensation defense mechanism, which involves overachieving in one area to compensate for deficiencies in another.
Choice C rationale:
Choice D rationale:
Journaling about career accomplishments after layoffs indicates sublimation, not compensation. Sublimation is a defense mechanism where unacceptable impulses or behaviors are transformed into socially acceptable actions or pursuits, like channeling frustration or disappointment into creative or productive activities such as journaling.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Give the client protamine if signs of magnesium sulfate toxicity occur. Protamine is not the antidote for magnesium sulfate toxicity. Calcium gluconate or calcium chloride is used to counteract the effects of magnesium sulfate toxicity by antagonizing the action of magnesium on the neuromuscular junction and the heart.
Choice B rationale:
Monitor the FHR via Doppler every 30 min. While fetal heart rate (FHR) monitoring is important during magnesium sulfate infusion due to the risk of fetal distress, using Doppler every 30 minutes may not provide continuous and accurate monitoring. Continuous electronic fetal monitoring is the standard of care in this situation.
Choice C rationale:
Restrict the client's total fluid intake to 250 mL/hr. Magnesium sulfate is excreted by the kidneys, so maintaining adequate urine output is crucial to prevent magnesium toxicity. Restricting fluid intake to 250 mL/hr would likely reduce urine output, leading to an increased risk of magnesium sulfate accumulation in the body, which could be harmful.
Choice D rationale:
Measure the client's urine output every hour. Monitoring urine output is essential during magnesium sulfate infusion as it helps assess renal function and magnesium excretion. Adequate urine output (at least 30 mL/hr) is necessary to prevent magnesium toxicity. Therefore, measuring the client's urine output every hour is a critical nursing intervention to ensure the safety of the client.
Correct Answer is D
Explanation
A.Taping the tube to the child's cheek is not a recommended practice. It can cause skin irritation, discomfort, or even accidental removal of the tube. Proper securing of the tube to the abdomen using appropriate devices is the preferred method to prevent dislodgement.
B.Applying lubricant to the site is not necessary or recommended. The gastrostomy tube should be kept clean and dry. If any secretions or debris are present, they should be gently cleaned with mild soap and water, followed by thorough rinsing and drying.
C.Some gastrostomy tubes require an extension set for feeding, especially low-profile devices (e.g., button-type gastrostomy tubes). This extension makes it easier to administer feeds or medications and can be removed afterward. However, this is not typically part of routine site care.
D.Securing the tubing to the child's abdomen helps prevent accidental dislodgement or pulling of the gastrostomy tube. This can be done using appropriate securing devices, such as adhesive dressings or commercially available tube holders, as recommended by the healthcare provider.
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