A nurse is caring for a client who states, "No wonder we can't get control of my pain! You don't even believe me when I tell you how much I hurt!" Which of the following defense mechanisms should the nurse identify the client using?
Conversion
Displacement
Introjection
Projection
The Correct Answer is D
Rationale:
A. Conversion: Conversion involves the expression of psychological stress through physical symptoms without an underlying medical cause. The client is describing real pain rather than expressing a psychological conflict as a physical symptom, so this does not match conversion.
B. Displacement: Displacement occurs when a person redirects emotions or feelings from the original source to a safer target. The client is addressing the nurse directly about pain management, not redirecting feelings onto another target, so this is not displacement.
C. Introjection: Introjection involves internalizing the beliefs or values of another person. The client is expressing frustration about pain management rather than adopting someone else’s values or attitudes, so introjection does not apply here.
D. Projection: Projection occurs when a person attributes their own feelings, motives, or thoughts onto someone else. In this case, the client is suggesting that the nurse does not believe them, which reflects the client projecting their feelings of frustration and mistrust onto the nurse.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Use gauze to secure an arm board to the involved extremity: Using gauze alone to secure an arm board is not recommended for a PICC line, as it can cause pressure, restrict circulation, and does not provide adequate stabilization. Specialized securement devices or adhesive dressings are preferred to maintain catheter integrity and prevent complications.
B. Measure the arm circumference above the insertion site daily: Daily measurement of the arm circumference helps detect early signs of swelling, infiltration, or thrombophlebitis, which are potential complications of PICC lines. Monitoring for changes allows prompt intervention and helps ensure safe catheter function.
C. Schedule an MRI postprocedure to verify placement: MRI is not used to verify PICC placement. Catheter tip placement is typically confirmed with chest X-ray or fluoroscopy immediately after insertion, which is the standard method for ensuring correct placement in the superior vena cava.
D. Administer sedation for the procedure: PICC line insertion is generally performed under local anesthesia, not systemic sedation. Routine sedation is not indicated for this minimally invasive procedure unless the client has severe anxiety or special considerations, making it unnecessary in standard care.
Correct Answer is D
Explanation
Rationale:
A. Abdomen: The abdominal skin may be loose due to age-related changes, weight fluctuations, or prior pregnancies, making it less reliable for assessing dehydration in older adults. Lifting skin here may give a false impression of skin turgor.
B. Shoulder: Skin over the shoulder can be affected by aging, sun exposure, or decreased subcutaneous tissue, which can distort the assessment of hydration status. It is not the preferred site for older adults.
C. Neck: The skin of the neck is thin and may show wrinkles or sagging unrelated to hydration. Assessing turgor here is less accurate in older clients and may overestimate skin elasticity changes due to aging.
D. Sternum: The skin over the sternum is relatively less affected by age-related changes and provides a more reliable site for assessing turgor in older adults. Lifting this area allows the nurse to evaluate hydration status more accurately without interference from natural skin laxity elsewhere.
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