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

To address the client’s cultural needs, the most appropriate nursing action would be to ask the client directly about their specific cultural needs and preferences. This allows the nurse to provide care that is tailored to the individual client and respects their cultural beliefs and practices.

A. The client is unwilling to accept the treatment being oﬀered. B. The client states that they will never attack the neighbor again. C. The client plans to move out of state immediately upon discharge from the hospital. D. The client is a threat to himself and others.

Correct Answer is D

Explanation

A client can be kept in the hospital after the initial 72-hour hold if they are deemed to be a threat to themselves or others. This determination is typically made by a mental health professional who evaluates the client’s behavior and mental state. If the client is considered to be a danger, they may be held involuntarily for further treatment and observation.

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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

To address the client’s cultural needs, which of the following nursing actions would be most appropriate?

Correct Answer is D

Explanation

A nurse is admitting a client to the psychiatrist unit after attacking a neighbor. The nurse should know that the client can be kept in the hospital after the 72 hours hold is over when which of the following conditions is met?

Correct Answer is D

Explanation

A nurse is leading a family therapy session for a mother, father, and two adolescent siblings. Which of the following statements should the nurse recognize as an example of manipulating?

A female client asks about her male nurse's girlfriend and social activities. Which of the following is the best response by the nurse?

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