A nurse is caring for an adolescent who states, "I joined the track and field team, so I won't argue with my brothers anymore." The nurse should identify that the client is using which of the following defense mechanisms?
Denial
Sublimation
Regression
Repression
The Correct Answer is B
A. Denial is incorrect. Denial involves refusing to acknowledge reality or a distressing situation, which is not evident in this scenario. The adolescent is aware of the conflict and has chosen a constructive way to address it.
B. Sublimation is correct. Sublimation is the process of channeling unacceptable impulses (such as frustration or aggression) into socially acceptable activities (such as sports or creative pursuits). By joining the track and field team instead of arguing with his brothers, the adolescent is redirecting energy into a positive outlet.
C. Regression is incorrect. Regression occurs when an individual reverts to an earlier stage of development in response to stress. Examples include an older child suddenly sucking their thumb or having temper tantrums. The adolescent in this scenario is demonstrating maturity, not regression.
D. Repression is incorrect. Repression involves unconsciously blocking distressing thoughts or emotions from awareness. The adolescent is not avoiding or forgetting about the conflict but is instead managing it through physical activity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Anorexia: This is not a common or serious adverse effect of heparin. It is not usually a priority for reporting to the provider.
B. Epistaxis: This is correct. Heparin is an anticoagulant, and one of the major risks associated with its use is bleeding. Epistaxis (nosebleeds) is a common sign of bleeding that could be a result of heparin therapy, and it should be reported to the provider promptly.
C. Bradycardia: Bradycardia is not a common adverse effect of heparin. Heparin primarily affects clotting mechanisms, not heart rate.
D. Weight gain: Weight gain is not a typical adverse effect of heparin. If the weight gain is significant or linked to fluid retention, it may need to be assessed, but it is not a typical reaction to heparin.
Correct Answer is C
Explanation
A. WBC 13,000/mm3 is slightly elevated and might indicate an infection, but it is not critically high in the context of COPD. The nurse should still monitor the client for signs of infection but is unlikely to require immediate intervention.
B. Potassium 3.7 mEq/L is within the normal range (3.5–5.0 mEq/L) and does not require reporting.
C. Hgb 20 g/dL is elevated and should be reported. High hemoglobin levels can indicate dehydration, polycythemia, or other conditions related to chronic hypoxia, which is common in COPD. This value is above the normal range (12–18 g/dL for adults) and requires further evaluation.
D. Iron 150 mcg/dL is within the normal range (50–170 mcg/dL for adults) and does not require reporting.
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