Nokea
Following a train accident, the nurse triages a group of victims. When the nurse asks how one of the clients is feeling, the client states matter-of-factly, 'Look at all the rescue trucks. It's like watching a movie.' Which defense mechanism does the nurse identify that the client is using?
- A. Dissociation.
- B. Regression.
- C. Projection.
- D. Denial.
Correct Answer: A
Rationale: Dissociation involves detaching from reality to cope with trauma, as seen in the client’s detached, movie-like perception of the accident. Regression, projection, and denial involve different coping mechanisms not reflected in this statement.
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A client having premature ventricular contractions states to the nurse, 'I'm so afraid that something bad will happen.' Which action by the nurse provides the most immediate help to the client?
- A. Telephoning the client's family
- B. Using a television to distract the client
- C. Having a staff member stay with the client
- D. Giving reassurance that nothing will happen to the client
Correct Answer: C
Rationale: When a client experiences fear, the nurse can provide a calm, safe environment by offering appropriate reassurance, using therapeutic touch, and having someone remain with the client as much as possible. Options 1 and 2 do not address the client's fear, and option 4 provides false reassurance.
The significant other of a client diagnosed with Graves' disease expresses concern regarding the client's bursts of temper, nervousness, and an inability to concentrate on even trivial tasks. On the basis of this information, the nurse should identify which concern for the client?
- A. Grief
- B. Socialization issues
- C. Issues related to sensory perception
- D. Trouble with coping with a disease process
Correct Answer: D
Rationale: A client with Graves' disease may become irritable, nervous, or depressed. The signs and symptoms in the question support option 4. The information in the question does not support the remaining options.
The nurse notes that an assigned client is lying tense in bed and staring at the cardiac monitor. The client states, 'There sure are a lot of wires around there. I sure hope we don't get hit by lightning.' Which is the most appropriate nursing response?
- A. Your family can stay tonight if they wish.'
- B. Would you like a mild sedative to help you relax?'
- C. The hospital is well equipped to shield a lightning strike.'
- D. Yes, all the wires must be scary. Let's talk about the cardiac monitor.'
Correct Answer: D
Rationale: The nurse should initially validate the client's concern and then assess the client's knowledge regarding the cardiac monitor. This gives the nurse an opportunity to provide client education if necessary. None of the remaining options address the client's concern. In addition, pharmacological interventions should be considered only if necessary.
The nurse provides care for a client diagnosed with paranoia. Two days after admission, the client refuses to give any information other than name and age. Which action is most important for the nurse to take?
- A. Tell the client that the hospital is a safe place.
- B. Urge the client to reveal more information.
- C. Focus on developing a trusting relationship with the client.
- D. Introduce the client to other clients on the unit.
Correct Answer: C
Rationale: Building trust is critical for clients with paranoia, who may be suspicious and guarded. A trusting relationship encourages engagement and cooperation, making it the priority over reassurance, urging disclosure, or socialization.
The nurse is giving a client diagnosed with heart failure home care instructions for use after hospital discharge. The client interrupts, saying, 'What's the use? I'll never remember all of this, and I'll probably die anyway!' The nurse determines that the client's statement is most likely due to which psychosocial concern?
- A. Anger about the new medical regimen
- B. The teaching strategies used by the nurse
- C. Insufficient financial resources to pay for the medications
- D. Anxiety about the ability to manage the disease process at home
Correct Answer: D
Rationale: Anxiety and fear often develop after heart failure, and they can further tax the failing heart. The client's statement is made in the middle of receiving self-care instructions. There is no evidence in the question to support option 1, 2, or 3.