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 C
Explanation
Rationale
A. In heart failure exacerbation, decreased cardiac output can lead to poor peripheral perfusion, potentially manifesting as weak or diminished pedal pulses. However, in the context of acute symptoms such as palpitations or chest discomfort, assessing the rhythm and rate of central pulses (like the apical pulse) may be more immediate and informative.
B. Capillary refill time assesses peripheral perfusion and can indicate circulatory status. Prolonged capillary refill (>2 seconds) may indicate poor perfusion, which could occur in heart failure exacerbation due to reduced cardiac output. It is a valuable assessment, but in this scenario, focusing on more central aspects such as the heart rhythm is typically more immediate.
C. Assessing the rhythm of the apical pulse is crucial in this scenario. The client's sensation of "flopping" in the chest suggests palpitations or irregular heartbeats, which could indicate arrhythmias such as atrial fibrillation or other dysrhythmias.
D. Skin elasticity primarily assesses hydration status and may provide information about overall skin integrity but is less directly related to the acute symptoms described by the client. While important in general assessments, it does not directly address the urgent need to assess for arrhythmias or irregular heartbeats.
Correct Answer is ["21"]
Explanation
To calculate the flow rate in gtt/min, you can use the formula: (Volume in mL * Drop factor) / Time in
minutes.
For 1 L of lactated Ringer's IV, which is 1000 mL, to be infused over 12 hours, with an IV administration set that delivers 15 gtt/mL, the calculation would be: (1000 mL * 15 gtt/mL) / (12 hours * 60 minutes/hour).
This simplifies to (15000 gtt) / (720 minutes), which equals approximately 20.83 gtt/min.
Therefore, the nurse should regulate the infusion to 21 gtt/min, rounding to the nearest whole
number.
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