Nokea
A father suspected of child abuse tells the nurse, 'I shouldn't have grabbed him so hard. I had a really bad day at work and got all stressed out. The kid just wouldn't listen to me.' The defense mechanism used by the father is:
- A. Projection
- B. Displacement
- C. Undoing
- D. Compensation
Correct Answer: B
Rationale: Displacement involves redirecting emotions (stress from work) onto a less threatening target (child). Projection, undoing, and compensation do not apply.
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A veteran is admitted with a diagnosis of chronic post-traumatic stress disorder. After being placed in the treatment room, he begins to pace frantically and make references to 'highway one.' As the nurse approaches him, he retreats to the corner and sits on the floor with his arms and legs pulled tight to his body. The client is experiencing a:
- A. Hallucination
- B. Phobic reaction
- C. Delusion
- D. Flashback
Correct Answer: D
Rationale: The behavior and reference to 'highway one' suggest a flashback, where the client is reliving a traumatic event, common in PTSD.
The nurse is caring for a newborn who has a cleft palate. Which of the following actions should the nurse take to promote oral intake? Select all that apply.
- A. Use specialty bottles or nipples
- B. Burp the newborn often when feeding
- C. Feed the newborn in an upright position
- D. Initiate feeding as soon as possible after birth
- E. Encourage the mother to exclusively breastfeed
Correct Answer: A,B,C
Rationale: Specialty bottles, frequent burping, and upright positioning facilitate feeding and reduce aspiration risk in cleft palate. Early feeding is appropriate but not specific, and exclusive breastfeeding is often challenging.
The afternoon following a thyroidectomy, the client experiences all of the following. Which one indicates to the nurse that the client is experiencing a serious complication?
- A. A sore throat
- B. Pain at the surgical site
- C. Temperature of 100.2°F
- D. Sudden hoarseness
Correct Answer: D
Rationale: Sudden hoarseness post-thyroidectomy may indicate vocal cord paralysis or hematoma compressing the airway, a serious complication requiring immediate attention. Sore throat, surgical pain, or mild fever are expected.
An adult woman who broke her right ankle is seen in the physician's office one week after the cast was applied. Which observation indicates to the office nurse that the client is using crutches correctly?
- A. The client moves the left crutch forward, then the right foot, then the right crutch, and finally the left foot.
- B. The client moves the left crutch and the right foot together, and then moves the right crutch and the left foot together.
- C. The client moves the left foot and the crutches forward while bearing weight on the right foot.
- D. The client bears weight on the left foot, and then moves the right foot and the crutches forward.
Correct Answer: A
Rationale: The four-point crutch gait (left crutch, right foot, right crutch, left foot) is stable and correct for a non-weight-bearing right ankle, ensuring balance and safety.
All of the following clients need attention. Which one should the nurse go to first?
- A. The nursing assistant reports that a client who had a T3 spinal cord transection several months ago has a severe headache and blurred vision.
- B. The nursing assistant needs help turning a client who had a CVA.
- C. The physician is about to examine a client who has multiple sclerosis and requests that the nurse be present.
- D. A client who has amyotrophic lateral sclerosis needs help with ambulating.
Correct Answer: A
Rationale: Severe headache and blurred vision in spinal cord injury suggest autonomic dysreflexia, a life-threatening emergency, prioritizing immediate attention over turning, examination, or ambulation.