Nokea
The mother of a teenager is told that her son has recently been found stealing from other students at school. The mother's response is, 'I cannot think about that today.' The nurse determines that this mother is using which defense mechanism?
- A. Suppression
- B. Repression
- C. Sublimation
- D. Undoing
Correct Answer: A
Rationale: The correct answer is A, Suppression. Suppression involves a conscious effort to avoid dealing with distressing thoughts or feelings. In this case, the mother is consciously choosing not to think about her son's behavior. Choice B, Repression, involves unconsciously blocking out distressing thoughts or feelings. Choice C, Sublimation, is the channeling of unacceptable impulses into socially acceptable behaviors, which is not demonstrated in this scenario. Choice D, Undoing, is a defense mechanism where a person tries to undo or reverse a negative thought or action by performing a contrary behavior, which is not applicable here.
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A client in the intensive care unit is being mechanically ventilated, has an indwelling urinary catheter in place, and is exhibiting signs of restlessness. Which action should the nurse take first?
- A. Review the heart rhythm on cardiac monitors
- B. Check urinary catheter for obstruction
- C. Auscultate bilateral breath sounds
- D. Give PRN dose of lorazepam (Ativan)
Correct Answer: B
Rationale: When a client in the intensive care unit is mechanically ventilated, has an indwelling urinary catheter, and is restless, the priority action is to check the urinary catheter for obstruction. Restlessness in this context could be due to a blocked catheter causing discomfort or urinary retention, which needs immediate attention to prevent complications. Reviewing the heart rhythm on cardiac monitors can be important but is not the priority in this scenario. Auscultating bilateral breath sounds is also important in a ventilated client but addressing the potential immediate issue of a blocked catheter takes precedence. Giving a PRN dose of lorazepam should not be the first action without addressing the underlying cause of restlessness.
A client with chronic kidney disease has an arteriovenous (AV) fistula in the left forearm. Which observation by the nurse indicates that the fistula is patent?
- A. Distended, tortuous veins in the left hand
- B. The left radial pulse is 2+ bounding
- C. Auscultation of a thrill on the left forearm
- D. Assessment of a bruit on the left forearm
Correct Answer: C
Rationale: Auscultation of a thrill on the left forearm is the correct observation indicating that the AV fistula is patent. A thrill is a palpable vibration or buzzing sensation felt over the fistula, indicating the presence of blood flow. Choices A, B, and D do not directly assess the patency of the fistula. Distended, tortuous veins in the left hand may indicate venous hypertension; a bounding radial pulse could suggest increased blood flow through an artery, but it does not confirm fistula patency; assessment of a bruit indicates turbulent blood flow, but it does not confirm patency.
A young adult who is hit with a baseball bat on the temporal area of the left skull is conscious when admitted to the ED and is transferred to the Neurological Unit to be monitored for signs of closed head injury. Which assessment finding is indicative of a developing epidural hematoma?
- A. Altered consciousness within the first 24 hours after injury
- B. Confusion immediately following the injury
- C. Headache that resolves quickly
- D. Brief loss of consciousness with a lucid interval
Correct Answer: A
Rationale: The correct answer is A. Epidural hematoma often presents with a brief loss of consciousness followed by a lucid interval and then a rapid decline in consciousness. Therefore, altered consciousness within the first 24 hours after the injury is indicative of a developing epidural hematoma. Choices B, C, and D are incorrect because confusion immediately following the injury, headache that resolves quickly, and brief loss of consciousness with a lucid interval are not specific signs of epidural hematoma.
A nurse is preparing to administer an intramuscular (IM) injection to a client. What is the most appropriate site to use for an IM injection in an adult?
- A. Dorsal gluteal muscle
- B. Vastus lateralis muscle
- C. Rectus femoris muscle
- D. Deltoid muscle
Correct Answer: B
Rationale: The correct answer is B: Vastus lateralis muscle. The vastus lateralis muscle is a recommended site for IM injections in adults due to its size and accessibility. The dorsal gluteal muscle is not recommended for IM injections in adults due to the proximity to major nerves and blood vessels, increasing the risk of injury. The rectus femoris muscle is not a common site for IM injections in adults. The deltoid muscle is typically used for IM injections in small-volume medications or vaccines, especially in adults.
When entering a client's room to administer an 0900 IV antibiotic, the nurse finds that the client is engaged in sexual activity with a visitor. Which actions should the nurse implement?
- A. Ignore the behavior and administer the IV antibiotic
- B. Tell the client to stop the inappropriate behavior
- C. Leave the room and close the door quietly
- D. Complete an unusual occurrence report
Correct Answer: C
Rationale: The correct action for the nurse in this situation is to leave the room and close the door quietly. This response respects the client's privacy, maintains professionalism, and avoids interrupting the client's personal moment. Choice A is incorrect because ignoring the behavior is not appropriate and may invade the client's privacy further. Choice B is incorrect as it can embarrass the client and the visitor, breaching their privacy and dignity. Choice D is also incorrect as the immediate priority is to respect the client's privacy and address the situation discreetly.