Two staff nurses were considered for promotion to head nurse. The promotion is announced via a memo on the unit bulletin board. The nurse who was not promoted tells a friend, 'Oh, well, I really didn't want the job anyway.' This is an example of:
- A. rationalization.
- B. denial.
- C. projection.
- D. compensation.
Correct Answer: A
Rationale: This is called the sour grapes form of rationalization. Rationalization is an unconscious form of self-deception in which excuses are made.
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A client goes to the mental health center for difficulty concentrating, insomnia, and nightmares. The client reports being raped as a child. The nurse should assess the client for further signs of:
- A. General anxiety disorder
- B. Schizophrenia
- C. Post-traumatic stress disorder
- D. Bipolar disorder
Correct Answer: C
Rationale: Childhood sexual abuse is strongly associated with post-traumatic stress disorder (PTSD), characterized by nightmares, insomnia, and concentration difficulties.
A nurse is instructing a person who had a left CVA and right lower extremity hemiparesis to use a quad cane. Which of the following is the most appropriate gait sequence?
- A. Place the cane in the patient's left upper extremity, encourage cane, then right lower extremity, then left upper extremity gait sequence.
- B. Place the cane in the patient's left upper extremity, encourage cane, then left lower extremity, then right upper extremity gait sequence.
- C. Place the cane in the patient's right upper extremity, encourage cane, then right lower extremity, then left upper extremity gait sequence.
- D. Place the cane in the patient's right upper extremity, encourage cane, then left lower extremity, then right upper extremity gait sequence.
Correct Answer: A
Rationale: The cane should be placed in the patient's strong upper extremity (left), and the sequence should coordinate the weak side (right leg) with the cane for support, followed by the strong side (left leg).
Support-system enhancement includes all of the following except:
- A. determining the barriers to using support systems.
- B. discussing ways to help with others who are concerned.
- C. exploring life problems of the support-team members.
- D. involving spouse, family, and friends in the care and planning.
Correct Answer: C
Rationale: The exploration of life problems of support-team members is not necessary to enhance the support system. Choices 1, 2, and 4 are all enhancements for a support system.
After group therapy, the female victim of intimate partner violence confides to the nurse that she does not feel in any immediate danger. Which of the following statements about victims of domestic violence is true?
- A. Victims of domestic violence are often the best predictors of their risk of harm.
- B. Victims of domestic violence often overestimate their safety risk.
- C. Victims of domestic violence are typically in a state of denial.
- D. Victims of domestic violence know that keeping peace with their partner is the best method of preventing another attack.
Correct Answer: A
Rationale: Victims of domestic violence are often correct at predicting their risk of harm. However, the nurse should ensure that the client is expressing herself authentically and is not trying to convince the nurse that there is no immediate danger. Further, proper authorities, such as the police, should be alerted to this reportable offense.
The difference between spirituality and religion is that spirituality is:
- A. a belief about a higher power.
- B. an individual's relationship with a higher power.
- C. organized worship.
- D. a belief in an invisible energy or ideal.
Correct Answer: B
Rationale: Religion can be considered a system of beliefs, practices, and ethical values about a divine or superhuman power or powers worshipped as the creator(s) and ruler(s) of the universe. Spirituality is a belief in or relationship with some higher power, creative force, driving being, or infinite source of energy.