Nokea
A client is admitted to a surgical unit with a diagnosis of cancer. The client is scheduled for surgery in the morning. When the nurse enters the room and begins the surgical preparation, the client states, 'I'm not having surgery. You must have the wrong person! My test results were negative. I'll be going home tomorrow.' The nurse recognizes the client's statement as indicative of which defense mechanism?
- A. Denial
- B. Psychosis
- C. Delusions
- D. Displacement
Correct Answer: A
Rationale: By definition, ego defense mechanisms are operations outside of a person's awareness that the ego calls into play to protect against anxiety. Denial is the defense mechanism that blocks out painful or anxiety-inducing events or feelings. In this case, the client cannot deal with the upcoming surgery for cancer and therefore denies the illness. Psychosis and delusions are not defense mechanisms. Displacement is the discharging of pent-up feelings on people who are less dangerous than those who initially aroused the feelings.
You may also like to solve these questions
A female victim of a sexual assault is being seen in the crisis center for a third visit. She states that although the rape occurred nearly 2 months ago, she still feels 'as though the rape just happened yesterday.' Which statement is most appropriate for the nurse to use as a response?
- A. In reality, the rape did not just occur. It has been over 2 months now.'
- B. What can you do to alleviate some of your fears about being assaulted again?'
- C. In time, our goal will be to help you move on from these strong feelings about your rape.'
- D. Tell me more about those aspects of the rape that cause you to feel like the rape just occurred.'
Correct Answer: D
Rationale: Option 4 allows for the client to express her ideas and feelings more fully and portrays a unhurried, nonjudgmental, supportive attitude. Clients need to be reassured that their feelings are normal and that they may freely express their concerns in a safe care environment. Although option 1 is true, it immediately blocks communication. Option 2 places the problem-solving totally on the client. Option 3 places the client's feelings on hold.
A client diagnosed with pulmonary edema exhibits severe anxiety. The nurse is preparing to carry out prescribed treatment. Which intervention should the nurse use to meet the needs of the client in a holistic manner?
- A. Ask a family member to stay with the client during the procedure.
- B. Give the client the call bell, and encourage its use if the client feels worse.
- C. Leave the client alone only to gather the required equipment and medications.
- D. Stay with the client, and ask another nurse to gather needed equipment and supplies.
Correct Answer: D
Rationale: The client with pulmonary edema is experiencing severe anxiety, which can exacerbate the condition and hinder treatment. Staying with the client provides emotional support and reassurance, addressing the psychosocial aspect of care, while delegating equipment gathering ensures efficient preparation for treatment. This holistic approach meets both the emotional and physical needs of the client. Option 1 may not be feasible or sufficient to address immediate anxiety. Option 2 does not provide active support, and option 3 leaves the client alone, which could increase anxiety.
A client is brought to the emergency department after overdosing on sleeping pills. The nurse is able to wake the client. Which question does the nurse ask first?
- A. Why did you take the medication?
- B. Can you share what is bothering you?
- C. How much medication did you take?
- D. Were you trying to kill yourself?
Correct Answer: C
Rationale: Determining the amount of medication taken is critical to assess the overdose’s severity and guide immediate treatment. Intent, emotional state, or reasons are secondary to ensuring physical safety.
A pregnant client receives news that the fetus has polycystic kidney disease. The client states to the nurse, 'I am so afraid my baby is going to die.' Which response by the nurse to the client is best?
- A. Finding out your baby has a serious health problem must be painful.
- B. How does your husband feel about this problem?
- C. How is your baby doing now?
- D. What you need to do is to focus on the present.
Correct Answer: A
Rationale: Acknowledging the client’s pain validates their fear and opens therapeutic communication, supporting emotional processing. Asking about others, focusing on the fetus’s status, or directing focus to the present dismisses the client’s expressed fear.
The nurse is interviewing a client diagnosed with chronic obstructive pulmonary disease (COPD) who has a respiratory rate of 35 breaths per minute and who is experiencing extreme dyspnea. On the basis of the nurse's observations, which is the appropriate client concern?
- A. Lack of knowledge about COPD
- B. Difficulty coping related with a situational crisis
- C. Negative self-image because of neurological deficit
- D. Restricted verbal communication because of a physical barrier
Correct Answer: D
Rationale: A client with COPD may suffer physical or psychological alterations that impair communication. To speak spontaneously and clearly, a person must have an intact respiratory system. Extreme dyspnea is a physical alteration that affects speech. There are no data in the question that support the remaining options.