A 40-year-old client is admitted to the hospital for tests to diagnose cancer. Since his admission, he has become dependent and demanding to the nursing staff. The nurse identifies this behavior as which defense mechanism?
- A. Denial
- B. Displacement
- C. Regression
- D. Projection
Correct Answer: C
Rationale: Regression involves reverting to an earlier developmental stage, such as dependency, in response to stress like a cancer diagnosis.
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The nurse discovers that a 78-year-old client who received hydralazine (Apresoline) 20 mg 45 minutes ago has a blood pressure of 70/40 mm Hg. The client has been on this dose of the medication for 3 years. Which of the following data is most likely significant in relation to the cause of the low blood pressure?
- A. Pedal pulses 11 (weak)
- B. Twenty-four-hour intake 1000 mL/day for past 2 days
- C. Serum potassium 3.3
- D. Pulse rate 150 bpm
Correct Answer: B
Rationale: (A, D) Decreased pulse volume and increased pulse rate are signs of an acute hypotensive episode. Inadequate fluid volume when taking vasodilators can result in a drop in blood pressure when vasodilation starts to physiologically occur as an action of the drug. A potassium level of 3.3 would not be associated with a significant drop in blood pressure.
Which term applies to the misconduct by a healthcare provider that results in harm to the patient?
- A. Negligence
- B. Tort
- C. Assault
- D. Malpractice
Correct Answer: D
Rationale: Malpractice refers to professional misconduct or negligence by a healthcare provider that causes harm to a patient. Negligence is a broader term tort is a civil wrong and assault involves intent to harm.
Which food selection would provide the most calcium for a client who is four months pregnant?
- A. Bowl of oatmeal
- B. Bran muffin
- C. One cup of yogurt
- D. Large orange
Correct Answer: C
Rationale: Yogurt is a rich source of calcium essential for fetal bone development during pregnancy. One cup provides approximately 300-400 mg of calcium significantly more than oatmeal bran muffins or oranges.
The client is diagnosed with pancreatitis. Which laboratory value is most indicative of this condition?
- A. Elevated amylase
- B. Decreased bilirubin
- C. Elevated hemoglobin
- D. Decreased white blood cell count
Correct Answer: A
Rationale: Elevated amylase is a key indicator of pancreatitis, as it is released from damaged pancreatic tissue. Bilirubin, hemoglobin, and white blood cell counts are less specific, though leukocytosis may occur.
Which of the following is a classic manifestation of glomerulonephritis?
- A. Hypertension
- B. Lassitude
- C. Fatigue
- D. Vomiting and diarrhea
Correct Answer: A
Rationale: Hypertension is a classic manifestation of glomerulonephritis due to fluid retention and renal dysfunction. Lassitude and fatigue may occur but are less specific and vomiting/diarrhea are not typical.
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