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A patient in the emergency department has no physical trabaja injuries but exhibits disorganized behavior and incoherence after a minor traffic accident. In which room should the nurse place the patient?
- A. Interview room furnished with a desk and two chairs.
- B. Small, empty storage room with no windows or furniture.
- C. Room with an examining table, instrument cabinets, desk, and chair.
- D. Nurse's office, furnished with chairs, files, magazines, and bookcases.
Correct Answer: A
Rationale: Individuals who are experiencing severe to panic-level anxiety require a safe environment that is quiet, non-stimulating, structured, and simple. A room with a desk and two chairs provides simplicity, few objects with which the patient could cause self-harm, and a small floor space around which the patient can move. A small, empty storage room without windows or furniture would be like a jail cell. The nurse's office or a room with an examining table and instrument cabinets may be overstimulating and unsafe.
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A person who feels unattractive repeatedly says, 'Although I'm not beautiful, I am smart.' This is an example of which defense mechanism?
- A. Repression
- B. Devaluation
- C. Identification
- D. Compensation
Correct Answer: D
Rationale: Compensation is an unconscious process that allows an individual to make up for deficits in one area by excelling in another area to raise self-esteem. Repression unconsciously puts an idea, event, or feeling out of awareness. Identification is an unconscious mechanism calling for an imitation of the mannerisms or behaviors of another. Devaluation occurs when the individual attributes negative qualities to self or to others.
A nurse wishes to teach alternative coping strategies to a patient experiencing severe anxiety. The nurse will first need to:
- A. verify the patient's learning style.
- B. create outcomes and a teaching plan.
- C. lower the patient's current anxiety level.
- D. assess how the patient uses defense mechanisms.
Correct Answer: C
Rationale: A patient experiencing severe anxiety has a significantly narrowed perceptual field and difficulty attending to events in the environment. A patient experiencing severe anxiety will not learn readily. Determining preferred modes of learning, devising outcomes, and constructing teaching plans are relevant to the task but are not the priority measure. The nurse has already assessed the patient's anxiety level. Using defense mechanisms does not apply.
Which client statement most supports a diagnosis of agoraphobia?
- A. Being afraid to go out seems ridiculous, but I can't go out the door.
- B. I'm sure I'll get over not wanting to leave home soon. It takes time.
- C. When I have a good incentive to go out, I can do it.
- D. My family says they like it now that I stay home.
Correct Answer: A
Rationale: Individuals who are agoraphobic generally acknowledge that the behavior is not constructive and that they do not really like it. Patients state they are unable to change the behavior. Patients with agoraphobia are not optimistic about change. Most families are dissatisfied when family members refuse to leave the house.
Which assessment finding indicates that a patient with moderate-to-severe anxiety has successfully lowered the anxiety level to mild?
- A. Patient asks, 'What's the matter with me?'
- B. Patient stays in a room alone and paces rapidly.
- C. Patient successfully concentrates on what the nurse is saying.
- D. Patient states, 'I don't want anything to eat. My stomach is upset.'
Correct Answer: C
Rationale: The ability to concentrate and attend to reality is increased slightly in mild anxiety and decreased in moderate-, severe-, and panic-level anxiety. Patients with high levels of anxiety often ask, 'What's the matter with me?' Staying in a room alone and pacing suggest moderate anxiety. Expressing a lack of hunger is not necessarily a criterion for evaluating anxiety.
A supervisor assigns a worker a new project. The worker initially agrees but feels resentful. The next day, when asked about the project, the worker says, 'I've been working on other things.' When asked 4 hours later, the worker says, 'Someone else was using the copier, so I couldn't finish it.' The worker's behavior demonstrates the use of what mechanism?
- A. Acting out
- B. Projection
- C. Suppression
- D. Passive aggression
Correct Answer: D
Rationale: A passive-aggressive person deals with emotional conflict by indirectly expressing aggression toward others. Compliance on the surface masks covert resistance. Resistance is expressed through procrastination, inefficiency, and stubbornness in response to assigned tasks. Acting out refers to behavioral expression of conflict. Projection is a form of blaming. Suppression is the conscious denial of a disturbing situation or feeling.