A nurse on a mental health unit is collecting data from a client who has an anxiety disorder. Which of the following actions by the client should the nurse identify as the use of displacement?

Punching the bed pillow when the staff denies the use of the telephone.

Writing a short story depicting themselves as a superhero.

Blaming their parent for a lack of attention received during childhood.

Having an aggressive outburst when meal selection is unavailable.

Answer and Explanation

The Correct Answer is A

Defense mechanisms are unconscious psychological strategies used to reduce anxiety and protect an individual from emotional distress. Displacement is a specific defense mechanism where an individual transfers emotional feeling from a threatening source to a safer or less threatening target. It is commonly seen in clients with anxiety disorders as a way of managing frustration or anger. Understanding defense mechanisms helps nurses interpret client behavior accurately and respond therapeutically.

Rationale:
A. Punching the bed pillow when staff denies the use of the telephone demonstrates displacement because the client redirects anger from the actual source (staff denial) onto a safer target (the pillow). This allows the expression of aggressive feelings without direct confrontation with the authority figure. It is a classic example of shifting emotional energy to a less threatening object.

B. Writing a short story depicting themselves as a superhero reflects sublimation or fantasy rather than displacement. The client is channeling emotions into creative expression or idealized thinking rather than transferring anger to another target. This defense mechanism does not involve redirecting aggression toward a substitute object.

C. Blaming their parent for lack of attention during childhood represents projection, where the individual attributes their own feelings or conflicts to another person. This is not displacement because the emotion is not redirected to a safer object but instead attributed to another individual as a source of blame.

D. Having an aggressive outburst when meal selection is unavailable reflects direct expression of frustration rather than displacement. The emotional response is directed at the immediate situation rather than being transferred to a substitute target. This indicates poor impulse control rather than use of a defense mechanism like displacement.

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Free Nursing Study Resources

Correct Answer is D

Explanation

Multiple sclerosis (MS) is a chronic, progressive demyelinating disorder of the central nervous system characterized by impaired nerve impulse conduction. Clients commonly experience muscle weakness, spasticity, fatigue, and decreased coordination, all of which interfere with mobility and self-care activities. Nursing care focuses on promoting independence while conserving energy and reducing physical strain. Adaptive devices and environmental modifications are key strategies to enhance functional ability in activities of daily living.

Rationale:
A. Planning hygiene care in the afternoon is not the most effective intervention because fatigue in multiple sclerosis often worsens later in the day. Clients typically have higher energy levels in the morning, making early scheduling more appropriate for self-care activities. Afternoon care may increase fatigue and reduce the client’s ability to participate independently.

B. Applying cold packs to joints is not primarily indicated for enhancing self-care ability in multiple sclerosis. Heat sensitivity is a known issue in MS, but cold therapy is used mainly to reduce symptom exacerbation rather than improve functional independence in daily activities. This intervention does not directly support self-care performance.

C. Encouraging hot showers is inappropriate because heat can worsen neurological symptoms in clients with multiple sclerosis. Increased body temperature may temporarily impair nerve conduction, leading to increased weakness, fatigue, and reduced coordination. This can further decrease the client’s ability to perform self-care activities safely.

D. Providing a raised toilet seat is an appropriate intervention because it reduces the effort required for transfers and improves safety during toileting. Clients with MS often experience lower extremity weakness and fatigue, making it difficult to lower and raise themselves from standard toilets. Adaptive equipment promotes independence, reduces fall risk, and supports effective self-care performance.

A. Koplik spots B. Beefy, red tongue C. Peeling of the hands and feet D. Paroxysmal cough

Correct Answer is D

Explanation

Pertussis, also known as whooping cough, is a highly contagious respiratory infection caused by Bordetella pertussis. It is characterized by inflammation of the upper respiratory tract leading to severe, uncontrollable coughing episodes. The illness typically progresses through stages, with the paroxysmal stage being most clinically distinctive. Recognition of hallmark symptoms is essential for early diagnosis, isolation, and prevention of transmission, especially in pediatric populations.

Rationale:
A. Koplik spots are small bluish-white lesions on an erythematous base found on the buccal mucosa and are a classic early sign of measles (rubeola), not pertussis. Their presence indicates a viral exanthem rather than a bacterial respiratory infection. They are not associated with pertussis.

B. A beefy, red tongue is commonly associated with conditions such as scarlet fever or vitamin deficiencies. It reflects mucosal inflammation or systemic infection affecting the oral cavity. This finding is not characteristic of pertussis, which primarily affects the respiratory tract rather than oral mucosa.

C. Peeling of the hands and feet is typically seen in conditions such as Kawasaki disease, where vasculitis leads to desquamation during the subacute phase. This manifestation is unrelated to pertussis, which does not involve systemic vasculitis or skin desquamation as a primary feature.

D. A paroxysmal cough is the hallmark manifestation of pertussis, characterized by sudden, intense coughing fits that may end with a whooping sound during inspiration. These episodes can be followed by vomiting or exhaustion due to increased intrathoracic pressure. This symptom results from toxin-mediated damage to the respiratory epithelium caused by Bordetella pertussis.

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Area assessed	Findings
Neurological	Drowsy but easy to arouse
Vital Signs	Temperature 35.3° C (95.5° F) Heart rate 60/min Respiratory rate 16/min Blood pressure 90/60 mm Hg Oxygen saturation 94% (oxygen at 2 L/min via nasal cannula) Rates pain as 1 on 0/10 pain scale.
Integumentary	Skin cool and moist to touch
Cardiopulmonary	Heart rate regular. Pedal pulse +1 bilateral. Lungs clear bilateral. Respirations even, nonlabored.
Abdomen	Abdomen soft, nondistended. Bowel sounds hypoactive in all four quadrants. 2x2 gauze with a clear transparent dressing intact to right lower and upper abdominal quadrant. Moderate amount of sanguineous drainage noted on the lower dressing.

A nurse on a mental health unit is collecting data from a client who has an anxiety disorder. Which of the following actions by the client should the nurse identify as the use of displacement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has multiple sclerosis. Which of the following interventions should the nurse include to enhance the client's ability to perform self-care?

Correct Answer is D

Explanation

A nurse is collecting data from a child who has pertussis. Which of the following manifestations should the nurse expect?

Correct Answer is D

Explanation

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