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A nurse is caring for a client who is participating in a therapy session for anger management. The client states that their recent behavior is due to the loss of their job. The nurse should identify that the client is using which of the following defense mechanisms?

Projection

Rationalization

Repression

Sublimation

Answer and Explanation

The Correct Answer is B

b. Rationalization

Explanation:

The correct answer is b. Rationalization.

Rationalization is a defense mechanism characterized by the individual's atempt to justify or explain their behavior or actions in a way that makes it more acceptable to themselves or others. It involves providing logical-sounding reasons or excuses to mask or minimize the real underlying reasons for their behavior.

In this scenario, the client is atributing their recent behavior to the loss of their job, using it as a justification or explanation for their actions. By blaming the job loss, they are rationalizing their behavior as a direct result of the circumstances they faced.

Option a, Projection, involves atributing one's own unacceptable thoughts, feelings, or behaviors to others.

This defense mechanism does not apply to the client's statement about their job loss.

Option c, Repression, involves the unconscious blocking of unwanted thoughts or feelings. It does not relate to the client's behavior or their explanation for it.

Option d, Sublimation, is a defense mechanism where an individual channels or redirects unacceptable impulses or emotions into socially acceptable behaviors or activities. It is not applicable in this context since the client is not expressing their emotions or impulses through alternative constructive means.

By identifying the client's explanation as rationalization, the nurse recognizes the defense mechanism being used and gains insight into how the client is coping with their emotions and justifying their behavior in response to the job loss. This understanding can guide the nurse in providing appropriate support and interventions to help the client manage their anger more eﬀectively.

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Correct Answer is C

Explanation

Elevating the legs helps to reduce swelling and promotes venous return, which is beneficial for a client with phlebitis. This action improves circulation and aids in preventing the formation of blood clots.

Rolls the extra stocking material down to the client's knee: This action is incorrect because elastic antiembolic stockings should be applied evenly and smoothly without any excess material. Rolling down the extra material can create folds and wrinkles, which can compromise the effectiveness of the stockings and potentially cause discomfort or impaired circulation.

Massages the legs before applying the stockings: Massaging the legs before applying antiembolic stockings is not recommended. Massaging can stimulate blood flow and may dislodge any existing blood clots, posing a risk of embolism. It is important to handle the legs gently and avoid any aggressive or manipulative actions that can disturb the clots.

Positions the client in a chair before applying the stockings: Positioning the client in a chair before applying antiembolic stockings is not the correct action. It is preferable to have the client lie flat in a supine position, with the legs elevated, while applying the stockings. Lying flat helps improve venous return and ensures proper alignment and positioning of the stockings.

A. Constipation: Constipation is not a common or significant side effect of cefazolin. While antibiotics can sometimes cause gastrointestinal disturbances such as diarrhea or nausea, constipation is unlikely to be a major concern for this medication. The adolescent should be encouraged to maintain hydration and a balanced diet, but constipation is not a priority symptom to report in this case. B. Elevated skin patches: Elevated skin patches or rashes could be a sign of an allergic reaction to cefazolin, but this is not the most immediate or critical symptom to monitor for in the context of the question. If an allergic rash develops, the adolescent should certainly report it, but elevated skin patches are more general and not directly associated with a serious or common side effect of cefazolin. Immediate concerns would be other signs of an allergic reaction, such as swelling or difficulty breathing. C. Ringing in the ears: Ringing in the ears (tinnitus) can be a sign of ototoxicity, a known side effect of cefazolin, especially when administered in high doses or for prolonged periods. Ototoxicity can affect hearing and balance, and tinnitus is an early symptom. This is a serious issue that should be reported immediately, as the drug might need to be adjusted or discontinued to prevent permanent damage to the ears. D. Depression: While depression is a serious condition that can affect adolescents, it is not a known side effect of cefazolin. If an adolescent experiences mood changes or symptoms of depression, these should be addressed, but they are unlikely to be directly related to the medication. Depression should always be taken seriously and managed, but it is not a primary concern related to cefazolin use.

Correct Answer is C

Explanation

c. Ringing in the ears.

Explanation:

Cefazolin is an antibiotic medication that belongs to the class of cephalosporins. While it is generally safe and well-tolerated, it can have potential side eﬀects that should be monitored and reported to the healthcare provider. One of the potential side eﬀects of cefazolin is ototoxicity, which can manifest as ringing in the ears (tinnitus) or other hearing disturbances. If the adolescent experiences any ringing in the ears or changes in hearing while taking cefazolin, it should be reported to the healthcare provider for further evaluation.

Options a, b, and d are not specifically associated with the use of cefazolin. Constipation can occur due to various reasons unrelated to this medication. Elevated skin patches may be indicative of an allergic reaction or other skin condition but are not specific to cefazolin. Depression is not a common side eﬀect of cefazolin and should be evaluated separately if experienced by the adolescent.

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A nurse is caring for a client who is participating in a therapy session for anger management. The client states that their recent behavior is due to the loss of their job. The nurse should identify that the client is using which of the following defense mechanisms?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring an assistive personnel (AP) who is applying elastic antiembolic stockings for a client who has phlebitis. Which of the following actions by the AP indicates that they are performing the skill correctly?

Correct Answer is C

Explanation

A nurse is reinforcing teaching with an adolescent who has a new prescription for cefazolin. For which of the following findings should the nurse instruct the adolescent to monitor and report to the provider?

Correct Answer is C

Explanation

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