A nurse is caring for a client who states, "I am under a great deal of stress at work, but I am able to forget my work and concentrate on my family when I get home at night." The nurse should identify that the client is demonstrating which of the following defense mechanisms?

Repression

Compartmentalization

Regression

Projection

Answer and Explanation

The Correct Answer is B

Choice A reason : Repression is a defense mechanism that involves unconsciously blocking unpleasant feelings, desires, or experiences from one's awareness. It is a way for the ego to protect itself from things that the individual cannot cope with at the moment. In the scenario provided, the client does not seem to be unconsciously blocking out the stress but is instead consciously choosing to focus on different aspects of their life at different times.

Choice B reason : Compartmentalization is a defense mechanism where an individual separates different aspects of their life, allowing them to handle conflicting values or emotions by keeping these aspects in separate 'compartments' in their mind. This seems to be what the client is doing by separating work stress from family life, thus being able to concentrate on family when at home despite the stress at work.

Choice C reason : Regression is a defense mechanism that leads an individual to revert to an earlier stage of development when faced with stress. An example would be an adult throwing a tantrum when they don't get their way, which is not what the client is demonstrating in the scenario⁴.

Choice D reason : Projection is a defense mechanism where an individual attributes their own unacceptable thoughts, feelings, or motives to another person. For instance, someone who is angry at their colleague may accuse the colleague of being hostile towards them. The client's statement does not indicate that they are projecting their feelings onto others⁵.

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Correct Answer is C

Explanation

Choice A reason : The term "alert" is an objective finding in the nursing assessment. It refers to the client's level of consciousness and responsiveness to stimuli, which can be directly observed and measured by the nurse during the evaluation. Being alert is a state that is evident through the client's behavior, responses, and interactions.

Choice B reason : "Pacing" is an objective finding. It is a visible behavior that can be observed and documented by the nurse without the need for interpretation or reliance on what the client says. Pacing can be quantified by the number of times the client walks back and forth in a given period.

Choice C reason : "Anxiety" is a subjective finding because it is based on the client's personal feelings and cannot be directly observed or measured by the nurse. It is reported by the client and requires the nurse to rely on the client's expression of their emotional state.

Choice D reason : "Restless" is an objective finding. Restlessness can be observed as physical movements, such as the inability to stay still, fidgeting, or frequent changes in position. These are behaviors that the nurse can see and document.

A. Decreased blood pressure B. Dilated pupils C. Bronchial airway constriction D. Hypoglycemia

Correct Answer is B

Explanation

Choice A reason : Decreased blood pressure is not a typical response to the fight-or-flight reaction. During this response, blood pressure usually increases due to the release of stress hormones like adrenaline, which cause the heart to beat faster and harder.

Choice B reason : Dilated pupils are a common manifestation of the fight-or-flight response. This physiological change allows more light into the eyes, which can improve vision and help an individual to better assess the situation and respond to potential threats.

Choice C reason : Bronchial airway constriction is not associated with the fight-or-flight response. In fact, the bronchial airways typically dilate to increase airflow and oxygen intake to prepare the body for action.

Choice D reason : Hypoglycemia, or low blood sugar, is not a direct result of the fight-or-flight response. The body actually mobilizes glucose stores, leading to elevated blood sugar levels, to provide energy for muscles during a stress response.

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A nurse is caring for a client who states, "I am under a great deal of stress at work, but I am able to forget my work and concentrate on my family when I get home at night." The nurse should identify that the client is demonstrating which of the following defense mechanisms?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data on a client who reports feeling stress and anxiety. The client appears restless and is pacing. The client is alert and oriented to person, place, and time. Which of the following findings is subjective?

Correct Answer is C

Explanation

A nurse is assisting with teaching a class about physical manifestations associated with the fight-or-flight response to stress. Which of the following manifestations should the nurse include?

Correct Answer is B

Explanation

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