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A school nurse is assessing a female high school student who is overly concerned about her appearance. The client's mother states, 'That's not something to be stressed about!' Which is the most appropriate nursing response?
- A. Teenagers! They don't know a thing about real stress.
- B. Stress occurs only when there is a loss.
- C. When you are in poor physical condition, you can't experience psychological well-being.
- D. Stress can be psychological. A threat to self-esteem may result in high stress levels.
Correct Answer: D
Rationale: The correct answer is D. Stress can manifest as physical or psychological. A perceived threat to self-esteem can be as stressful as a physiological change. Choice A is dismissive of the teenager's concerns and does not address the issue professionally. Choice B is incorrect as stress can result from various factors, not just loss. Choice C oversimplifies the relationship between physical condition and psychological well-being, neglecting the impact of mental stressors on overall health.
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Which should the individual recognize as an example of the defense mechanism of repression?
- A. A student aware of the need to study for tomorrow's test goes to a movie instead.
- B. A woman whose son was killed in Iraq does not believe the military report.
- C. A man who is unhappily married goes to school to become a marriage counselor.
- D. A woman was raped when she was 12 and no longer remembers the incident.
Correct Answer: D
Rationale: Repression is a defense mechanism where distressing thoughts, feelings, or memories are pushed out of conscious awareness to protect the individual from emotional pain. In this scenario, the woman's inability to recall the traumatic event of being raped at the age of 12 indicates repression in action. Choices A, B, and C do not represent repression. Choice A reflects procrastination, choice B suggests denial, and choice C indicates sublimation as the man is channeling his unhappiness into a constructive pursuit.
The healthcare provider is preparing to provide medication instruction for a patient. Which of the following understandings about anxiety will be essential to effective instruction?
- A. Learning is best when anxiety is moderate to severe.
- B. Learning is enhanced when anxiety is mild.
- C. Panic-level anxiety helps the provider teach better.
- D. Severe anxiety is characterized by intense concentration and enhances the attention span.
Correct Answer: B
Rationale: Mild anxiety sharpens the senses, increases the perceptual field, and results in heightened awareness of the environment, which enhances learning. As anxiety increases, attention span decreases, making learning more difficult. Therefore, mild anxiety is more conducive to effective instruction compared to moderate to severe anxiety, panic-level anxiety, or severe anxiety. Choice A is incorrect because moderate to severe anxiety impairs learning. Choice C is incorrect as panic-level anxiety can be overwhelming and hinder the learning process. Choice D is incorrect because severe anxiety typically leads to impaired attention span rather than enhancing it.
A healthcare professional is assessing a client diagnosed with anorexia nervosa. Which of the following findings should the healthcare professional expect? Select one that doesn't apply.
- A. Amenorrhea
- B. Lanugo
- C. Hypotension
- D. Hyperkalemia
Correct Answer: D
Rationale: Findings in a client diagnosed with anorexia nervosa include amenorrhea, lanugo, hypotension, and bradycardia. Hyperkalemia is not typically associated with anorexia nervosa. In anorexia nervosa, electrolyte imbalances often lead to hypokalemia, which is low potassium levels, due to malnutrition and potential purging behaviors. Hyperkalemia, high potassium levels, is not a common finding in individuals with anorexia nervosa.
A client with bipolar disorder is experiencing a depressive episode. Which of the following interventions should the nurse not implement?
- A. Agree with the client's delusions to avoid confrontation.
- B. Monitor for signs of suicidal ideation
- C. Promote a regular sleep schedule
- D. Discourage the expression of negative feelings
Correct Answer: A
Rationale: During a depressive episode in bipolar disorder, it is crucial not to agree with the client's delusions to avoid reinforcing false beliefs. Monitoring for signs of suicidal ideation is essential for safety. Promoting a regular sleep schedule can help stabilize mood. Discouraging the expression of negative feelings is not recommended as it is important to allow clients to express their emotions and feel heard.
A client has a history of excessive drinking, which has led to multiple arrests for driving under the influence (DUI). The client states, 'I work hard to provide for my family. I don't see why I can't drink to relax.' The nurse recognizes the use of which defense mechanism?
- A. Projection
- B. Rationalization
- C. Regression
- D. Sublimation
Correct Answer: B
Rationale: The nurse should recognize that the client is using rationalization, a common defense mechanism. Rationalization involves creating logical reasons to justify unacceptable feelings or behaviors. In this scenario, the client is justifying excessive drinking by linking it to hard work and the need for relaxation, masking the true underlying issue of alcohol abuse. Projection involves attributing one's thoughts or feelings to others, regression involves reverting to an earlier stage of development, and sublimation involves channeling unacceptable impulses into socially acceptable activities, none of which are demonstrated in the client's statement.