Exhibits
Click to specify which client statement or behaviors is most likely associated with each of the listed defense mechanisms. Some statements or behaviors may be consistent with more than one mechanism. Each column must have at least one response selected.
The client seems unemotional when talking about needing to rebuild her house.
The client says that she sometimes forgets why she is in the hospital.
The client discusses moving to Hawaii instead of returning to rebuild her house.
The client is frightened that the hospital will burn down.
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"B"}}
Client Statement: A. The client seems unemotional when talking about needing to rebuild her house.
Suppression fits here because the client appears detached or unemotional when discussing the significant emotional task of rebuilding her house after it collapsed. This suggests a deliberate effort to suppress or minimize the emotional impact of the situation.
Client Statement: C. The client discusses moving to Hawaii instead of returning to rebuild her house.
The client's discussion of moving to Hawaii instead of facing the reality of rebuilding her house reflects a form of fantasy. It suggests a retreat into an idealized scenario (moving to a distant, idyllic location) to avoid dealing directly with the trauma and stress associated with rebuilding her home.
Client Statement: B. The client says that she sometimes forgets why she is in the hospital.
Isolation can be inferred here because the client's statement about forgetting why she is in the hospital may indicate a psychological distancing or detachment from the traumatic events that led her there. It suggests a coping mechanism where she separates her emotional distress (related to the house collapse) from the practical reality of being hospitalized and receiving treatment.
Client Statement: D. The client is frightened that the hospital will burn down.
This statement fits into the defense mechanisms of fantasy. The client encounters thoughts of the hospital burning and her house burns down.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D"]
Explanation
Rationale
A. This is generally a good practice for clients who may have difficulty ambulating to the bathroom due to their condition. It promotes safety and reduces the risk of falls, especially during episodes of dyspnea.
B. A supine position can increase venous return to the heart and exacerbate symptoms of heart failure by increasing preload. This can lead to increased pulmonary congestion and respiratory distress. Therefore, this observation requires immediate intervention.
C. Providing a low sodium diet aligns with managing heart failure by reducing fluid retention and workload on the heart. This observation does not require immediate intervention unless there are specific dietary restrictions or concerns.
D. In heart failure, fluid restriction is often necessary to prevent fluid overload and exacerbation of symptoms. Having a full pitcher of water accessible to the client could lead to excessive fluid intake, which is concerning and requires immediate intervention.
E. A saline lock allows access for intravenous medications or fluids if needed. Its presence does not necessarily indicate a need for immediate intervention unless it is not functioning properly or if there are signs of infection or infiltration.
Correct Answer is A
Explanation
Rationale
A. Osteoarthritis is characterized by the gradual destruction of joint cartilage. Cartilage serves as a cushion between the bones in a joint, and its deterioration leads to pain, stiffness, and reduced joint function. As the cartilage wears away, bones may rub directly against each other, causing further pain and damage.
B. Osteoarthritis is primarily a degenerative condition rather than an inflammatory one. While mild inflammation can occur in OA, it is not as prominent as in autoimmune conditions like rheumatoid arthritis. In OA, inflammation is secondary to cartilage damage rather than a primary driver of the disease process.
C. Loss of bone mineral density is more characteristic of osteoporosis, a condition where bones become weak and brittle. Osteoporosis involves a decrease in bone mass throughout the skeleton, whereas osteoarthritis specifically targets the joints and affects cartilage rather than bone density.
D. An infectious process in the synovial fluid could indicate septic arthritis, which is characterized by infection in the joint space. This is typically associated with acute symptoms such as severe joint pain, swelling, warmth, and fever.
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