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 {"dropdown-group-1":"B"}

Explanation

Choice A rationale:
Sinus tachycardia is not a cause, but a consequence of hyperkalemia.

Choice B rationale:
The client has a history of diabetes, hypertension, coronary artery disease, and end-stage renal disease, which are all risk factors for developing hyperkalemia (high levels of potassium in the blood). She also missed her scheduled dialysis session, which could have caused a buildup of potassium in her blood. Some of the signs and symptoms of hyperkalemia include fatigue, weakness, muscle cramps, tingling sensation in arms and legs, and cardiac arrhythmias such as sinus tachycardia (a fast heart rate). The other options are not consistent with the client's data or condition.

Choice C rationale:
Hypermagnesemia can also cause muscle weakness and cardiac arrhythmias, but they are less likely in this scenario since magnesium is not affected by dialysis

Choice D rationale:
Hypokalemia can also cause muscle weakness and cardiac arrhythmias, but they is less likely in this scenario since potassium is usually elevated in ESRD.

A. Provide a supportive, structured environment for meals. B. Assess weight, vital signs, potassium, and other electrolytes. C. Discuss alternative strategies for binging and purging. D. Monitor the client after meals for possible vomiting.

Correct Answer is B

Explanation

Choice A rationale:
Providing a supportive, structured environment for meals is an important aspect of the overall care plan for individuals with bulimia. However, it should not be the first intervention when a client is admitted with potential physical complications. Addressing the client's physical condition and safety is the initial priority.

Choice B rationale:
This is the correct initial intervention. Bulimia can lead to severe medical complications, including electrolyte imbalances, which can be life-threatening. Assessing the client's weight, vital signs, and electrolyte levels is crucial to determine the severity of physical issues and guide appropriate medical interventions.

Choice C rationale:
Discussing alternative strategies for binging and purging is an important aspect of treatment for bulimia, but it should follow the initial assessment of the client's physical condition. Addressing the client's medical needs takes precedence over discussing alternatives.

Choice D rationale:
While monitoring the client for possible vomiting is important in the care of individuals with bulimia, it should not be the first intervention when the client is admitted. Assessing the client's physical status and addressing potential medical complications should come before monitoring for specific behaviors.

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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.

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Naxlex Comprehensive Predictor Exams

Correct Answer is {"dropdown-group-1":"B"}

Explanation

A female client with bulimia is admitted to the mental health unit after she disclosed to a friend that she purges after meals. Which intervention should the nurse implement first?

Correct Answer is B

Explanation

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