Patient Data

Exhibits here

The nurse engages the client in conversation about her feelings and some of her coping mechanisms.

Click to specify which client statement or behavior 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 but may have more than one answer selected.

The client discusses moving to Hawaii instead of returning to rebuild her house.

The client seems unemotional when talking about needing to rebuild her house.

The client states that she sometimes forgets why she is in the hospital.

The client is frightened that the hospital will burn down.

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"D"}}

A. The client discusses moving to Hawaii instead of returning to rebuild her house.

Defense Mechanism: Fantasy

Explanation: The client may be using fantasy as a way to escape from the painful reality of her situation. Discussing moving to a place like Hawaii, which may represent an idealized and stress-free environment, suggests a desire to avoid confronting the challenges and emotions associated with her current circumstances.

B. The client seems unemotional when talking about needing to rebuild her house.

Defense Mechanism: Isolation

Explanation: Isolation, or emotional isolation, occurs when an individual separates emotions from the events or thoughts associated with them. The client's lack of emotional response when discussing rebuilding her house suggests that she may be isolating her feelings to avoid distress.

C. The client states that she sometimes forgets why she is in the hospital.

Defense Mechanism: Suppression

Explanation: Suppression involves the conscious effort to avoid thinking about distressing thoughts or memories. The client's statement that she sometimes forgets why she is in the hospital may indicate an attempt to suppress or avoid focusing on the traumatic event that led to her hospitalization.

D. The client is frightened that the hospital will burn down.

Defense Mechanism: Denial

Explanation: Denial involves refusing to accept the reality of a situation, which can manifest as irrational fears or beliefs. The client's fear that the hospital will burn down may reflect a form of denial, as she might be projecting her fear of the collapse (a traumatic event) onto another catastrophic event, thereby avoiding dealing with her actual trauma.

Summary of Answers:

A. Fantasy - The client discusses moving to Hawaii instead of returning to rebuild her house.
B. Isolation - The client seems unemotional when talking about needing to rebuild her house.
C. Suppression - The client states that she sometimes forgets why she is in the hospital.
D. Denial - The client is frightened that the hospital will burn down.

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Correct Answer is ["B","C","D","E","F"]

Explanation

Choice A rationale:
This finding suggests that the client may not be fully disclosing her symptoms or may not be aware of their significance. It should be investigated further.

Choice B rationale:
The blood pressure and heart rate are within an acceptable range, indicating that the client's blood pressure is relatively stable.

Choice C rationale:
A potassium level of 3.6 mEq/L falls within the reference range, indicating that the client's potassium level is within normal limits.

Choice D rationale:
The client's commitment to attending dialysis appointments is a positive sign, as regular dialysis is crucial for managing end-stage renal disease.

Choice E rationale:
If the client recognizes the need to resume her Lisinopril for blood pressure control, it indicates her understanding of the medication's importance in managing her hypertension.

Choice F rationale:
The client's willingness to incorporate nutrient-rich foods like dark green vegetables and potatoes into her diet is a positive sign for improving her nutritional status, which can be beneficial for her overall health. However, dietary changes should be discussed with her healthcare provider to ensure they are appropriate for her condition.

A. Use an incentive spirometer. B. Monitor the urinary stream for the decrease in output. C. Report when hematuria becomes pink-tinged. D. Restrict physical activities.

Correct Answer is C

Explanation

Choice A rationale:
Using an incentive spirometer is not directly related to the post-TUNA discharge instructions for a client with BPH. Incentive spirometry is typically used to improve lung function and prevent respiratory complications.

Choice B rationale:
Monitoring the urinary stream for a decrease in output may be important, but it is a general instruction that may not be specific to the TUNA procedure. The primary focus after TUNA is often on monitoring for complications related to the procedure.

Choice C rationale:
Reporting when hematuria (blood in the urine) becomes pink-tinged is important. While some degree of hematuria is expected after TUNA, a change in color to pink or any other concerning changes should be reported to the healthcare provider as it could indicate complications.

Choice D rationale:
There is typically no need to restrict physical activities after a TUNA procedure. In fact, healthcare providers often encourage patients to resume normal activities gradually unless otherwise instructed due to specific complications.

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A. The client discusses moving to Hawaii instead of returning to rebuild her house.

B. The client seems unemotional when talking about needing to rebuild her house.

C. The client states that she sometimes forgets why she is in the hospital.

D. The client is frightened that the hospital will burn down.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data Exhibits The client has been in IMU unit for 3 days and the physician plans to discharge her home today. Select the client actions that were effective in her treatment.

Correct Answer is ["B","C","D","E","F"]

Explanation

A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). Which information should the nurse include in the discharge instructions?

Correct Answer is C

Explanation

The nurse is assessing a client who reports using cocaine several times in the past week. Which observations should the nurse expect on assessment?

Prior to initiating a treatment regimen with the antidepressant sertraline, it is most important for the nurse to obtain which information?

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