A nurse is speaking to the family of a Trauma victim. The nurse is blocking out the siren and alarm noises while speaking with the client’s family. They ask,” How can you be so calm and focused with all this noise going on?” The nurse is practicing which defense mechanism?

Disassociation-adaptive

Denial-adaptive

Rationalization-maladaptive

Altruism-maladaptive

Answer and Explanation

The Correct Answer is A

Disassociation is a defense mechanism that involves mentally separating oneself from a stressful or traumatic situation in order to maintain a sense of calm and focus. In this scenario, the nurse is able to block out the sirens and alarms, which may be causing stress and anxiety, and maintain a calm and focused demeanor while speaking with the client's family. This is an adaptive use of disassociation because it allows the nurse to provide eﬀective care and support to the family despite the chaotic environment.

Denial is a defense mechanism that involves denying or minimizing the existence of a stressful or traumatic situation. Rationalization involves justifying or excusing one's behavior or actions. Altruism involves selﬂessly helping others as a way of dealing with one's own problems. In this scenario, none of these defense mechanisms are being used by the nurse.

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Correct Answer is D

Explanation

working with a client in crisis, the nurse’s priority intervention should be to ensure the client’s safety. This involves assessing the client’s risk for harm to themselves or others and taking appropriate measures to prevent harm. Once the client’s safety has been ensured, the nurse can then focus on other interventions such as decreasing the client’s anxiety and identifying previous experiences and coping methods used.

A. Communicate eﬀectively B. Document only what is needed to understand the client's situation C. Practice within own scope of practice D. Advocate and assist clients with their needs including emotional needs E. Maintain competencies and education.

Correct Answer is ["A","C","D","E"]

Explanation

Eﬀective communication can help to prevent misunderstandings and ensure that the client receives appropriate care.

Practicing within one’s scope of practice ensures that the nurse is providing care that is within their level of expertise and training.

Advocating for and assisting clients with their needs can help to ensure that they receive the care and support they need.

Maintaining competencies and education ensures that the nurse is up-to-date on best practices and able to provide high-quality care.

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A nurse is speaking to the family of a Trauma victim. The nurse is blocking out the siren and alarm noises while speaking with the client’s family. They ask,” How can you be so calm and focused with all this noise going on?” The nurse is practicing which defense mechanism?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While working with a client in crisis, the nurse understands which of the following interventions would be a priority.

Correct Answer is D

Explanation

Which of the following should a nurse utilize to assist in preventing liability from occurring? (Select all that apply.)

Correct Answer is ["A","C","D","E"]

Explanation

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