Nokea
A nurse is caring for an adolescent who states, 'I joined the track and field team, so I won't argue with my brothers anymore.' The nurse should identify that the client is using which of the following defense mechanisms?
- A. Denial
- B. Sublimation
- C. Regression
- D. Repression
Correct Answer: B
Rationale: Sublimation is correct. Sublimation is the process of channeling unacceptable impulses (such as frustration or aggression) into socially acceptable activities (such as sports or creative pursuits). By joining the track and field team instead of arguing with his brothers, the adolescent is redirecting energy into a positive outlet.
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A nurse overhears two assistive personnel (AP) in the nurses' station discussing a client who was recently admitted. Which of the following actions should the nurse take?
- A. Tell the APs to stop the conversation.
- B. Document the event in the client's progress notes.
- C. Inform the client of the APs' actions.
- D. Submit an incident report to the risk manager.
Correct Answer: A
Rationale: Telling the APs to stop the conversation is correct. Discussing client information in a public area violates HIPAA (Health Insurance Portability and Accountability Act) privacy regulations. The nurse should immediately intervene and remind the APs about maintaining client confidentiality.
A nurse is reinforcing teaching with a client who is scheduled for a Holter monitor. Which of the following instructions should the nurse include?
- A. Avoid showering while wearing the monitor.
- B. Exercise more than usual during the test.
- C. Remove the monitor before sleeping.
- D. Keep a diary of activities.
Correct Answer: D
Rationale: Keeping a diary of activities helps correlate symptoms with heart rhythm changes recorded by the Holter monitor.
A nurse is caring for a client who is receiving IV vancomycin. Which of the following findings should the nurse report to the provider?
- A. Redness at the IV site
- B. Weight gain
- C. Bradycardia
- D. Hypotension
Correct Answer: A
Rationale: Redness at the IV site may indicate phlebitis or infiltration, requiring immediate reporting to prevent complications.
A nurse is reinforcing teaching about hand hygiene with a newly licensed nurse. Which of the following information should the nurse include in the teaching?
- A. Use hot water to wash hands.
- B. Apply friction to hands for 10 seconds.
- C. Dry hands starting from forearm to fingers.
- D. Interlace the fingers while rubbing hands together.
Correct Answer: D
Rationale: Interlacing the fingers while rubbing hands together is correct. Interlacing the fingers and rubbing them together ensures that all surfaces of the hands, including between the fingers, are properly cleaned. This method is recommended in the CDC hand hygiene guidelines for thorough washing.
A community health nurse is assisting with the development of a pamphlet regarding choking hazards for toddlers. Which of the following foods should the nurse include?
- A. Oranges
- B. Potatoes
- C. Grapes
- D. Corn
Correct Answer: C
Rationale: Grapes are correct. Whole grapes are a known choking hazard for toddlers due to their size and shape, which can easily obstruct the airway. They should be cut into smaller pieces to reduce the risk.