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A nurse is admitting a client to an alcohol abuse program. The client states, "I'm here because of my boss. It was part of my job to go to parties and drink with clients.” The client's statement is an example of which of the following defense mechanisms?
- A. Reaction formation
- B. Compensation
- C. Rationalization
- D. Suppression
Correct Answer: C
Rationale: The correct answer is C: Rationalization. Rationalization is a defense mechanism where individuals justify their behaviors, feelings, or thoughts by providing logical reasons that may not be true. In this scenario, the client is justifying their excessive drinking by blaming it on their job requirement, which is a form of rationalization.
A: Reaction formation involves expressing the opposite of how one truly feels.
B: Compensation is making up for a deficiency in one area by excelling in another.
D: Suppression is consciously pushing unwanted thoughts or feelings out of one's mind.
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A nurse in the emergency department is creating a plan of care for a client experiencing alcohol intoxication. Which of the following interventions should the nurse plan to include? (Select all that apply.)
- A. Contact the laboratory to obtain a blood sample.
- B. Prepare the client for a CT scan.
- C. Check the client’s pupil reactivity.
- D. Obtain a urine specimen.
- E. Perform a developmental screening test.
Correct Answer: A, B, C, D
Rationale: The correct interventions for a client experiencing alcohol intoxication are A, B, C, and D. A blood sample is crucial to assess alcohol levels. A CT scan may be needed to rule out head trauma or other underlying issues. Checking pupil reactivity can indicate neurological status. Obtaining a urine specimen helps assess kidney function and possible drug use. Choice E, performing a developmental screening test, is not relevant to the immediate care needs of an individual with alcohol intoxication.
A nurse is caring for a client who has bipolar disorder and is running around the unit asking people to dance with her. Which of the following interventions should the nurse take?
- A. Turn on a dance video so the client can burn off excess energy.
- B. Offer the client a low-calorie snack in return for stopping the behavior.
- C. Walk the client outside and sit with her in the garden area.
- D. Observe the client closely for the development of aggressive behavior.
Correct Answer: C
Rationale: The correct answer is C: Walk the client outside and sit with her in the garden area. This intervention helps the client to redirect their energy in a positive and calming manner. Being outdoors can provide a change of environment, fresh air, and can help the client feel more grounded. It also offers a distraction from the impulsive behavior and promotes relaxation. Turning on a dance video (choice A) may further stimulate the client's behavior rather than calming them down. Offering a snack (choice B) may reinforce the behavior and is not addressing the underlying issue. Observing for aggressive behavior (choice D) is important but does not actively address the client's current behavior.
A nurse is caring for a client who was admitted with delirium tremens five days ago. The client seeks permission from the nurse before performing activities of daily living. This behavior indicates which of the following findings?
- A. The client is ready for discharge.
- B. The client is able to function independently.
- C. The client may be having a recurrence of delirium tremens.
- D. The client is exhibiting dependency.
Correct Answer: D
Rationale: The correct answer is D: The client is exhibiting dependency. This behavior indicates that the client is relying on the nurse for permission before performing activities of daily living, suggesting a level of dependency. This is common in clients with delirium tremens as they may have cognitive impairment and need guidance for decision-making.
A: The client seeking permission does not necessarily indicate readiness for discharge.
B: The client seeking permission does not necessarily indicate ability to function independently.
C: There is no indication of a recurrence of delirium tremens based on seeking permission.
Summary: The correct answer, D, is supported by the client's behavior of seeking permission, indicating dependency. Other choices are incorrect as they do not align with the behavior exhibited by the client in this scenario.
A client commits suicide in an acute mental health facility. Which of the following is the priority intervention for staff following this incident?
- A. Provide professional counseling for staff members.
- B. Change policies for staff observation of clients who are suicidal.
- C. Identify cues in the client's behavior that might have warned them that he was contemplating suicide.
- D. Give the family an opportunity to talk about their feelings.
Correct Answer: C
Rationale: The correct answer is C: Identify cues in the client's behavior that might have warned them that he was contemplating suicide. This is the priority intervention because understanding the warning signs can help prevent future suicides by recognizing and addressing high-risk behaviors. Providing counseling (A) is important but not the immediate priority. Changing policies (B) may be necessary in the long term but does not address the current situation. Giving the family an opportunity to talk (D) is important for support but does not directly address staff intervention.
A nurse is assessing an adolescent female client who has anorexia nervosa. Which of the following findings should the nurse expect?
- A. Tachycardia
- B. Constipation
- C. Menorrhagia
- D. Hyperkalemia
Correct Answer: B
Rationale: The correct answer is B: Constipation. In anorexia nervosa, a lack of adequate nutrition intake can lead to decreased gastrointestinal motility, resulting in constipation. Tachycardia (A) is common due to the body's response to malnutrition. Menorrhagia (C) is unlikely as anorexia nervosa often leads to amenorrhea. Hyperkalemia (D) is less likely as potassium levels tend to be low due to decreased food intake.