A nurse is caring for a client who has a new diagnosis of metastatic lung cancer. The client states, "I can't think about that until after my first grandchild is born next week." The nurse should identify the client's statement as indicating the maladaptive use of which of the following defense mechanisms?

Compensation

Sublimation

Regression

Suppression

Answer and Explanation

The Correct Answer is D

A.   Compensation involves overachieving in one area to make up for deficiencies in another area, which is not evident in the client's statement.
B.   Sublimation involves channeling unacceptable impulses into socially acceptable activities, which is not demonstrated in the client's statement.
C.   Regression involves reverting to an earlier stage of development in the face of stress, which is not evident in the client's statement.
D.   Suppression involves consciously avoiding or postponing dealing with a stressor, which aligns with the client's statement of delaying thinking about their diagnosis until after a significant event.

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Correct Answer is ["A","B","D","F","I"]

Explanation

A. The blood alcohol level of 510 mg/dL indicates severe intoxication and requires monitoring for potential complications, such as respiratory depression or alcohol withdrawal.

B. The client's recent loss of both parents is significant and may contribute to the relapse of alcohol use disorder. It warrants further assessment of the client's coping mechanisms and emotional state.
C. Smoking history:

While the client's smoking history may be relevant to their overall health, it is not a priority for follow-up in this scenario where the client's alcohol intoxication and potential withdrawal symptoms are the primary concerns.
D. The client's recent consumption of alcohol, as reported by the family member, is crucial information for assessing the risk of alcohol withdrawal and planning appropriate
interventions.

E. Cardiac assessment:
The client's vital signs indicate normal sinus rhythm and stable blood pressure, suggesting no acute cardiac issues at present. Given the focus on alcohol intoxication and potential withdrawal, a comprehensive cardiac assessment is not immediately warranted.
F. The neurological assessment is essential to monitor for signs of alcohol withdrawal, such as tremors, hallucinations, or seizures, given the client's history of alcohol use disorder and current intoxication.
G. Genitourinary assessment:

While assessing the genitourinary system is important in a comprehensive nursing assessment, there are no indications in the provided information to suggest acute genitourinary issues requiring immediate follow-up. The client's current symptoms and history primarily suggest alcohol intoxication and potential withdrawal.
H. Respiratory assessment:

The client's respiratory assessment indicates clear lung sounds and adequate oxygen saturation, suggesting no acute respiratory distress at the time of admission. While
respiratory status should be monitored, it is not a priority for immediate follow-up compared to the client's alcohol intoxication and potential withdrawal.
I. Assessing the gastrointestinal system is important to evaluate the client's nutritional status, assess for signs of liver disease or other gastrointestinal complications associated with alcohol use disorder, especially considering the reported weight loss and minimal appetite.

A. Buprenorphine B. Bupropion C. Disulfiram D. Chlordiazepoxide

Correct Answer is D

Explanation

A. Buprenorphine is not typically indicated for alcohol withdrawal; it is primarily used in the management of opioid dependence.
B. Bupropion is an antidepressant medication and is not indicated for the treatment of acute alcohol withdrawal.
C. Disulfiram is used as a deterrent to alcohol consumption in individuals who have achieved abstinence and is not indicated for acute alcohol withdrawal.
D. Chlordiazepoxide is a benzodiazepine medication commonly used to manage alcohol withdrawal symptoms, such as anxiety and agitation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a mental health facility is admitting a client. Exhibits A nurse is caring for a client who was admitted for alcohol use disorder. Which of the following findings require follow-up by the nurse? Select all that apply.

Correct Answer is ["A","B","D","F","I"]

Explanation

A nurse is reviewing new prescriptions for a client who is experiencing acute manifestations of alcohol withdrawal. Which of the following medications should the nurse expect the provider to prescribe for this client?

Correct Answer is D

Explanation

A nurse is providing teaching to the caregiver of an older adult client who has Alzheimer's disease and is being cared for at home. The client wanders at night and has a history of previous falls. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

A nurse is assessing a client who has post-traumatic stress disorder. Which of the following findings should the nurse expect? (Select all that apply.)

A nurse is obtaining a medical history from a client who is requesting a prescription for bupropion for smoking cessation. Which of the following assessment findings in the client's history should the nurse report to the provider?

A nurse is conducting an admission interview with a client who is experiencing mania. Which of the following findings should the nurse report to the provider?

A nurse is assessing a client during a follow-up visit at a behavioral health clinic. The client reports that they have not been taking the prescribed antipsychotic medication on a regular basis. Which of the following actions should the nurse take to improve medication adherence?

A nurse observes the caregiver of a client who has Alzheimer's disease throwing magazines on the floor and crying. Which of the following actions should the case manager take first?

A nurse is assessing a client's communication patterns. The client states, "My partner is always criticizing me." This statement is an example of which of the following types of dysfunctional communication?

A nurse is caring for a client who has physical restraints applied. The nurse determines that the restraints should be removed when which of the following occurs?