Nokea
The client with a myocardial infarction comes to the nurse's station stating that he is ready to go home because there is nothing wrong with him. Which defense mechanism is the client using?
- A. Rationalization
- B. Denial
- C. Projection
- D. Conversion reaction
Correct Answer: B
Rationale: The correct answer is B: Denial. The client displaying denial refuses to acknowledge the reality of having a myocardial infarction. Rationalization (choice A) involves making excuses for behavior, not denying a condition. Projection (choice C) is attributing one's thoughts or feelings to others, not denying an illness. Conversion reaction (choice D) is converting psychological distress into physical symptoms, which is not evident in this scenario. Therefore, denial is the defense mechanism being used in this situation.
You may also like to solve these questions
A 25-year-old male is brought to the emergency room with a piece of metal in his eye. Which action by the nurse is correct?
- A. Use a magnet to remove the object.
- B. Rinse the eye thoroughly with saline.
- C. Cover both eyes with paper cups.
- D. Administer eye drops immediately.
Correct Answer: C
Rationale: Covering both eyes with paper cups is the correct action as it helps prevent consensual movement of the affected eye. Attempting to remove the object with a magnet might cause trauma, making choice A incorrect. While rinsing the eye with saline may be necessary, it should be ordered by a doctor and is not the initial action for the nurse, making choice B incorrect. Administering eye drops immediately, as in choice D, is not appropriate in this scenario and does not address the primary concern of preventing further damage by limiting eye movement.
Upon arrival at the emergency room, the client presents with severe burns to the left arm, hands, face, and neck. What action should take priority?
- A. Starting an IV
- B. Applying oxygen
- C. Obtaining blood gases
- D. Medicating the client for pain
Correct Answer: B
Rationale: In a client with severe burns to the face and neck, airway assessment and supplemental oxygen are crucial. Therefore, applying oxygen is the priority to ensure adequate oxygenation for the client. This intervention takes precedence over other actions to stabilize the client's condition. Starting an IV for fluid resuscitation is the next appropriate step following ensuring oxygenation (Choice A). While pain management is important, it is a secondary priority after ensuring oxygenation and fluid resuscitation, making medicating the client for pain a later intervention (Choice D). Obtaining blood gases (Choice C) is not the immediate priority in this scenario and would typically be ordered by the healthcare provider based on the client's condition and response to initial interventions.
A nurse is teaching the mother of an 11-month-old infant how to clean the infant's teeth. The nurse tells the mother to take which action?
- A. Use a small amount of toothpaste and a soft-bristle toothbrush
- B. Use water and a cotton swab and rub the teeth
- C. Use diluted fluoride and rub the teeth with a soft washcloth
- D. Dip the infant's pacifier in maple syrup so that the infant will suck
Correct Answer: C
Rationale: The correct action when cleaning an infant's teeth is to use water and a cotton swab to gently rub the teeth. This method helps in removing any food particles or plaque buildup without the risks associated with toothpaste ingestion. Using a small amount of toothpaste and a soft-bristle toothbrush is not recommended for infants as they may swallow the toothpaste, leading to potential fluoride ingestion issues. Using diluted fluoride and rubbing the teeth with a soft washcloth is unnecessary at this age since infants typically receive fluoride through other sources like formula. Dipping the infant's pacifier in maple syrup is highly inappropriate and poses a significant risk of tooth decay due to the high sugar content, which can harm the infant's teeth.
A man reports his wife is constantly cleaning, which interferes with family life. Friends avoid visiting due to feeling uncomfortable. The husband finds her cleaning even at night. The nurse should consult and recommend the husband help with therapy by:
- A. telling his wife to stop cleaning whenever he notices her actions.
- B. making a baseline record of the time the wife spends cleaning.
- C. decreasing the stimuli in the home.
- D. helping his wife with the cleaning.
Correct Answer: C
Rationale: The correct answer is to decrease the stimuli in the home. The wife's behavior suggests obsessive-compulsive disorder, an anxiety disorder. By reducing stimuli in the environment, such as clutter or triggers that prompt cleaning, it helps in managing the condition and promoting a calmer atmosphere. Option A is incorrect as directly telling the wife to stop can escalate her anxiety. Option B is not the priority initially, as addressing the root cause is more crucial. Option D may reinforce the behavior rather than addressing the underlying issue.
The physician has ordered a culture for the client with suspected gonorrhea. The nurse should obtain which type of culture?
- A. Blood
- B. Nasopharyngeal secretions
- C. Stool
- D. Genital secretions
Correct Answer: D
Rationale: A culture for gonorrhea is taken from the genital secretions as gonorrhea primarily affects the genital area. The culture is incubated in a warm environment to promote the growth of Neisseria gonorrhoeae, the bacterium causing gonorrhea. Genital secretions provide a direct sample from the site of infection, increasing the accuracy of diagnosis. Choices A, B, and C are incorrect as they are not suitable specimens for diagnosing gonorrhea. Blood cultures are used to detect bloodstream infections, nasopharyngeal secretions are collected for respiratory infections, and stool cultures are done to identify gastrointestinal infections, none of which are related to gonorrhea.