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A client recently had an abdominoperineal resection and colostomy. While the nurse changes the dressing, the client states, 'You think that it looks repulsive.' The nurse identifies that the client is using which defense mechanism?
- A. Projection
- B. Sublimation
- C. Compensation
- D. Intellectualization
Correct Answer: A
Rationale: The correct answer is Projection. Projection is the defense mechanism where unacceptable feelings and emotions are attributed to others. In this scenario, the client is projecting their own feelings of repulsion onto the nurse. Sublimation involves substituting socially acceptable feelings to replace threatening ones. Compensation refers to overachievement in a different area to cover up a weakness. Intellectualization is the use of mental reasoning to avoid facing emotional aspects of a situation.
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An older woman has lived alone since the death of her husband 10 years ago, and she has a long list of vague complaints. Which assessment is the priority for the home health nurse to perform?
- A. Assess for feelings of loneliness and isolation.
- B. Determine if the client has unresolved grief.
- C. Determine if there are safety issues.
- D. Ask about the availability of support systems.
Correct Answer: C
Rationale: The priority assessment for the home health nurse in this scenario is to determine if there are safety issues. The client is an older woman living alone with a long list of vague complaints, indicating several risk factors. Ensuring her safety should be the primary concern. While assessing for feelings of loneliness, isolation, or grief is important, ensuring the client's safety takes precedence due to her vulnerable situation. Although assessing the availability of support systems is essential in a home health assessment, safety issues must be addressed first given the client's profile.
A health care provider discusses with a client the need for an abdominoperineal resection and a colostomy. After the health care provider leaves the room, the client tells the nurse about being relieved that only minor surgery is necessary. Which psychological process explains this client's reaction?
- A. Reflection
- B. Regression
- C. Repudiation
- D. Reconciliation
Correct Answer: C
Rationale: The client's reaction of believing that only minor surgery is necessary when faced with the need for an abdominoperineal resection and a colostomy is an example of repudiation. Repudiation involves a refusal to acknowledge anticipated loss as a defense mechanism against the overwhelming stress of illness. The client is psychologically denying the seriousness of the situation.
The other choices are incorrect because:
- Reflection (Choice A) does not apply since the client is not contemplating the issues of the situation.
- Regression (Choice B) is not demonstrated as the client's behavior does not indicate reverting to an earlier stage of development.
- Reconciliation (Choice D) is not applicable as the client has not made a realistic adjustment to the illness but rather is in denial of its severity.
The client is in the maintenance stage based on the transtheoretical model of health behavior change. Which stage is the client in?
- A. Action
- B. Preparation
- C. Maintenance
- D. Contemplation
Correct Answer: C
Rationale: The client is in the maintenance stage of human behavior change. During this stage, the client has successfully incorporated the changes into their lifestyle. The maintenance stage typically begins 6 months after the action stage and continues indefinitely. The action stage lasts for 6 months from when the client initially incorporates the changes. In the preparation stage, the client starts realizing that the benefits of change outweigh the disadvantages and starts making small changes to prepare for major changes in the following month. The contemplation stage involves the client considering whether to make changes in the next 6 months. Therefore, in this scenario, the client's consistent adherence to the diet and exercise program for 8 months places them in the maintenance stage of behavior change.
Which of the following individuals is at the highest risk of suicide?
- A. An 80-year-old man who lost his wife last year
- B. A 36-year-old woman whose former neighbor committed suicide
- C. A 40-year-old married businessman
- D. A 46-year-old former alcoholic who has been sober for 12 years
Correct Answer: A
Rationale: The correct answer is an 80-year-old man who lost his wife last year. Certain factors increase the risk of suicide, such as recent loss of a loved one, in this case, the man's wife. The elderly are a high-risk group due to factors like social isolation, physical health issues, and bereavement. While experiencing a loss can affect anyone, the combination of age, loss of a spouse, and the associated emotional impact elevates the risk significantly. The other choices are not at the highest risk of suicide. A former alcoholic who has been sober for 12 years has taken steps towards recovery, reducing the immediate risk. A 40-year-old married businessman and a 36-year-old woman whose former neighbor committed suicide do not have the same level of immediate risk as the elderly man who recently lost his wife.
For which condition would electroconvulsive therapy (ECT) be used?
- A. Severe clinical depression
- B. Substance abuse disorders
- C. Antisocial personality disorder
- D. Psychosis occurring in schizophrenia
Correct Answer: A
Rationale: Electroconvulsive therapy (ECT) is indicated for severe clinical depression, especially in cases where clients do not respond well to psychotropic medications or require immediate intervention due to the severity of their depression. ECT is not typically used as a primary treatment for substance abuse disorders, antisocial personality disorder, or psychosis occurring in schizophrenia. While ECT is an effective intervention for severe depression, it is important to consider individual client needs and response to other treatment options before resorting to ECT.