Nokea
A client with a statement indicating the use of a defense mechanism.
Which of the following statements, if made by a client to the nurse, would indicate that the client is using the defense mechanism of conversion?
- A. I love my family with all my heart even though they don't love me.'
- B. I was unable to take my final exams because I was unable to write.'
- C. I don't believe I have diabetes. I feel perfectly fine.'
- D. If my wife was a better housekeeper I wouldn't have such a problem.'
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) indicates reaction formation (2) correct-client has converted his anxiety over school performance into a physical symptom that interferes with his ability to perform (3) indicates denial (4) indicates projection
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An intravenous pyelogram (IVP) is ordered for a client who is scheduled to have his left kidney removed because of hypertension and renal disease. Which of the following nursing actions has the highest priority the evening prior to the IVP?
- A. Administer a cathartic enema to cleanse the bowel.
- B. Obtain information about client allergies.
- C. Instruct the client to be NPO after midnight.
- D. Teach the client that x-rays will be taken at multiple intervals.
Correct Answer: B
Rationale: assessment, clients sensitive to iodine can develop anaphylaxis; client should be asked specifically about allergies to iodine; iodine is present in the radiopaque material that is injected IV
Which of the following assessments would be a priority when documenting the nursing history of a two-year-old child?
- A. The child's rituals and routines at home.
- B. The child's understanding of hospitalization.
- C. The child's ability to be separated from the parents.
- D. The parent's methods for dealing with the child's temper tantrums.
Correct Answer: A
Rationale: during a crisis such as hospitalization, children are able to establish a sense of security through consistency of the rituals and routines from home
The nurse is planning care for a 56-year-old man who returned from surgery for a bowel resection with an IV of 0.9% NaCl infusing at 100 cc/h into his left wrist. Which of the following actions, if performed by the nurse, is BEST?
- A. Change the IV tubing each time a new IV solution is hung.
- B. Cleanse the IV site with an alcohol swab using long strokes.
- C. Limit manipulation of the cannula at the IV insertion site.
- D. Adjust the drop rate to keep the total volume of IV fluids on schedule.
Correct Answer: C
Rationale: will prevent dislodgment of needle
The nurse is teaching a client with chronic obstructive pulmonary disease (COPD) about home oxygen therapy. Which of the following instructions should the nurse include?
- A. Use oxygen only when feeling short of breath.
- B. Store oxygen tanks near an open flame.
- C. Avoid smoking while using oxygen.
- D. Use a humidifier with oxygen at high flow rates.
Correct Answer: C
Rationale: Smoking near oxygen risks fire, a critical safety concern. Options A, B, and D are incorrect or unsafe.
A 20-year-old woman calls the outpatient clinic to schedule her first Papanicolaou's smear. The nurse should instruct the client to
- A. avoid intercourse for 48 hours before the examination.
- B. avoid douching for 24 hours prior to her appointment.
- C. withhold all foods and fluids 12 hours before the appointment.
- D. save her first voided urine specimen the morning of her appointment.
Correct Answer: B
Rationale: douching would affect appearance of cells in vaginal smear, would make test inaccurate