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The nurse who was not promoted then went to the utility room and slammed several cupboard doors while looking for Kleenex. This behavior exemplifies:
- A. displacement.
- B. sublimation
- C. conversion.
- D. reaction formation.
Correct Answer: A.
Rationale: Displacement unconsciously transfers emotions associated with a person, object, or situation to another less threatening person, object, or situation. In this scenario, the nurse slammed doors instead of expressing anger towards the promoted nurse or the administrator who made the promotion decision. Sublimation is the unconscious process of substituting constructive activity for unacceptable impulses. Since slamming cupboard doors is not a constructive activity, this choice is incorrect. Conversion involves transforming anxiety into physical symptoms, which is not demonstrated in the given behavior. Reaction formation keeps unacceptable feelings or behaviors out of awareness by displaying the opposite feeling or behavior, which is not the case here.
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A client is admitted with Ewing's sarcoma. Which symptoms would be expected due to this tumor's location?
- A. Hemiplegia
- B. Aphasia
- C. Nausea
- D. Bone pain
Correct Answer: D
Rationale: Ewing's sarcoma is a type of bone cancer that primarily affects the bones. Therefore, bone pain would be an expected symptom due to this tumor's location. Hemiplegia, which refers to paralysis on one side of the body, Aphasia, a language disorder, and Nausea are not typical symptoms of Ewing's sarcoma. While Nausea is a common symptom in various conditions, it is not specific to bone cancer like Ewing's sarcoma. Therefore, Bone pain is the most likely symptom associated with Ewing's sarcoma.
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.
A 60-year-old widower is hospitalized after complaining of difficulty sleeping, extreme apprehension, shortness of breath, and a sense of impending doom. What is the best response by the nurse?
- A. "You have nothing to worry about. You are in a safe place. Try to relax."?
- B. "Has anything happened recently or in the past that might have triggered these feelings?"?
- C. "We have given you a medication that helps to decrease feelings of anxiety."?
- D. "Take some deep breaths and try to calm down."?
Correct Answer: B
Rationale: Choice B is the best response as it shows empathy, acknowledges the patient's feelings, and opens the door for discussion about potential triggers for anxiety. This approach helps the patient explore the root cause of his anxiety and provides an opportunity for therapeutic communication. Choice A dismisses the patient's feelings and offers false reassurance, which may not address the underlying issue. Choices C and D do not encourage the patient to express his emotions or delve into the reasons behind his anxiety, hindering the therapeutic process.
The client with schizophrenia has become disruptive and requires seclusion. Which staff member can institute seclusion?
- A. The security guard
- B. The registered nurse
- C. The licensed practical nurse
- D. The nursing assistant
Correct Answer: B
Rationale: The registered nurse is the correct choice to institute seclusion for a client with schizophrenia. In healthcare settings, only a registered nurse or a physician can legally initiate seclusion. The security guard, licensed practical nurse, and nursing assistant do not have the authority to carry out this action. Therefore, options A, C, and D are incorrect.
Which of the following describes the stages of domestic violence in an intimate relationship?
- A. happiness, crisis, angry outburst, intervention
- B. honeymoon period, escalation of stress, outburst, reconciliation
- C. acting out and making up
- D. peace and calm, angry outburst, peace and calm, denial
Correct Answer: B
Rationale: The correct answer is B: 'honeymoon period, escalation of stress, outburst, reconciliation.' A pattern of behavior known as the cycle of abuse involves these stages. It starts with a honeymoon phase, followed by a buildup of stress, an outburst which may involve violence, and then reconciliation. This cycle is commonly observed in domestic violence situations. Choices A, C, and D do not accurately represent the stages of domestic violence in intimate relationships. Choice A mixes positive and negative elements, while choice C simplifies the complex dynamics of domestic violence. Choice D repeats 'peace and calm' inappropriately and includes 'denial,' which is not typically a stage in the cycle of abuse.