The nurse is assessing the drinking history of a client with a history of alcohol abuse. The client is being admitted after being found unresponsive in a public place. Which statement would indicate the use of defense mechanisms?
"I have no intention to stop drinking. I like the way it makes me feel."
"I have tried so many times to stop drinking. It is so hard."
I don't really have a problem with alcohol. I've just been having a streak of bad luck lately."
"I really need some help. My drinking is tearing my family apart."
The Correct Answer is C
A. "I have no intention to stop drinking. I like the way it makes me feel.": This is an example of denial but does not strongly indicate a defense mechanism.
B. "I have tried so many times to stop drinking. It is so hard.": This demonstrates acknowledgment of the problem and a desire for change, not a defense mechanism.
C. "I don't really have a problem with alcohol. I've just been having a streak of bad luck lately.": This is an example of rationalization, a defense mechanism where the individual justifies their behavior with excuses.
D. "I really need some help. My drinking is tearing my family apart.": This statement reflects insight and readiness for change, not a defense mechanism.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Methadone: Methadone is used for opioid withdrawal, not alcohol.
B. Benzodiazepines: Benzodiazepines, such as lorazepam or diazepam, are first-line medications to manage alcohol withdrawal symptoms, prevent seizures, and reduce the risk of delirium tremens.
C. Naloxone: Naloxone is used to reverse opioid overdose.
D. Diphenhydramine: While it may help with mild symptoms like sleep disturbance, it is not a primary treatment for withdrawal.
Correct Answer is D
Explanation
A. Place the client in a private room: While privacy can be helpful, it is not the priority intervention in alcohol withdrawal care.
B. Pad the side rails of the bed with towels: This is a safety measure to prevent injury during seizures but should follow the assessment of disorientation.
C. Accompany the client when ambulating: Fall prevention is important, but assessing the client’s level of disorientation takes precedence.
D. Determine the client's level of disorientation: The first step in care is assessing the client's mental status and level of disorientation to identify immediate needs and risks.
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