a nurse is caring for a patient who states, “I did not take my medication because my partner forgot to remind me.”. The nurse should identify that the patient is demonstrating which of the following defense mechanisms?

Choice A rationale
Skeletal muscles do not enable the heart to contract with each heartbeat. The heart has its own specialized muscle tissue known as cardiac muscle, which allows it to contract and pump blood throughout the body.
Choice B rationale
Skeletal muscles do not enable the bladder to contract during voiding. The detrusor muscle, a smooth muscle found in the wall of the bladder, contracts during urination to expel urine from the body.
Choice C rationale
Skeletal muscles do not enable the bronchioles to dilate in the lungs. The dilation and constriction of the bronchioles are controlled by the autonomic nervous system and the smooth muscles in the walls of the bronchioles.
Choice D rationale
Skeletal muscles do enable a hand to contract and form a fist. Skeletal muscles are responsible for all voluntary movements, including making a fist. When you want to make a fist, your brain sends a signal to the skeletal muscles in your hand and forearm, telling them to contract. This pulls on the tendons connected to your fingers, causing them to move and form a fist.

Choice A rationale
While prothrombin level is an important test in evaluating blood clotting disorders, it is not typically used in the initial diagnostic evaluations for a cerebrovascular accident (CVA) or stroke.
Choice B rationale
Brain CT or MRI scans are commonly used in the initial diagnostic evaluations for a CVA. These imaging tests can show bleeding in the brain, an ischemic stroke, a tumor, or other conditions.
Choice C rationale
A chest x-ray is not typically used in the initial diagnostic evaluations for a CVA. It is more commonly used to diagnose conditions affecting the lungs and heart.
Choice D rationale
A lumbar puncture, or spinal tap, may be used in some cases to help diagnose a CVA, but it is not typically part of the initial diagnostic evaluations.