Which should the nurse recognize as an example of the defense mechanism of repression?
- A. A woman whose son was killed in Iraq does not believe the military report.
- B. A man who is unhappily married goes to school to become a marriage counselor.
- C. A woman was raped when she was 12 and no longer remembers the incident.
Correct Answer: C
Rationale: The correct answer is C because repression is a defense mechanism in which traumatic memories are unconsciously blocked from awareness. In this scenario, the woman's inability to remember the rape incident at age 12 is a classic example of repression. She has pushed the memory out of consciousness to avoid the emotional distress associated with it.
Choice A is incorrect as it describes denial, where the woman refuses to accept the truth. Choice B is incorrect as it reflects sublimation, where the man channels his unhappiness into a positive pursuit. Choice D is incomplete, making it impossible to evaluate.
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When under stress, a client routinely uses an excessive amount of alcohol. Finding her drunk, her husband yells at her about the chronic alcohol abuse. Which reaction should the nurse recognize as the use of the defense mechanism of denial?
- A. Hiding liquor bottles in a closet
- B. Yelling at their son for slouching in his chair
- C. Burning dinner on purpose
- D. Saying to the spouse, I dont drink too much!
Correct Answer: D
Rationale: The correct answer is D because the client is using denial as a defense mechanism to cope with the stress of being confronted about her alcohol abuse. By saying "I don't drink too much," she is refusing to acknowledge the reality of her excessive alcohol consumption. This denial allows her to avoid facing the uncomfortable truth and the need for change.
A: Hiding liquor bottles in a closet is an example of a defense mechanism called displacement, not denial.
B: Yelling at their son for slouching in his chair is an example of a defense mechanism called projection, not denial.
C: Burning dinner on purpose is an example of a defense mechanism called passive-aggression, not denial.
A nursing instructor is teaching about specific phobias. Which student statement should indicate that learning has occurred?
- A. These clients do not recognize that their fear is excessive, and they rarely seek treatment.
- B. These clients have overwhelming symptoms of panic when exposed to the phobic stimulus.
- C. These clients experience symptoms that mirror a cerebrovascular accident (CVA).
- D. These clients experience the symptoms of tachycardia, dysphagia, and diaphoresis.
Correct Answer: B
Rationale: The correct answer is B because it accurately describes a key feature of specific phobias: individuals experience intense panic symptoms when exposed to the phobic stimulus. This indicates learning as it demonstrates understanding of the characteristic behavioral response in specific phobias. Choice A is incorrect as it describes characteristics of agoraphobia, not specific phobias. Choice C is incorrect as it describes symptoms of a stroke, not specific phobias. Choice D is incorrect as it lists symptoms that are not typically associated with specific phobias.
What is the priority nursing action during the orientation (introductory) phase of the nurseclient relationship?
- A. Acknowledge the clients actions and generate alternative behaviors.
- B. Establish rapport and develop treatment goals.
- C. Attempt to find alternative placement.
- D. Explore how thoughts and feelings about this client may adversely impact care.
Correct Answer: B
Rationale: The correct answer is B: Establish rapport and develop treatment goals. During the introductory phase of the nurse-client relationship, establishing rapport is essential to build trust and a therapeutic alliance. Developing treatment goals collaboratively with the client sets the foundation for the care plan. This action promotes client engagement and empowerment. Acknowledging client actions and generating alternative behaviors (A) is more suited for later phases. Attempting to find alternative placement (C) is not appropriate in the introductory phase. Exploring how thoughts and feelings impact care (D) is important but not the priority during the orientation phase.
After fasting from 10 p.m. the previous evening, a client finds out that the blood test has been canceled. The client swears at the nurse and states, You are incompetent! Which is the nurses best response?
- A. Do you believe that I was the cause of your blood test being canceled?
- B. I see that you are upset, but I feel uncomfortable when you swear at me.
- C. Have you ever thought about ways to express anger appropriately?
- D. Ill give you some space. Let me know if you need anything.
Correct Answer: B
Rationale: The correct answer is B: "I see that you are upset, but I feel uncomfortable when you swear at me." This response acknowledges the client's emotion while setting a boundary against inappropriate behavior. It demonstrates empathy towards the client's feelings without condoning the swearing. It also communicates the nurse's discomfort with the behavior, which can help in de-escalating the situation.
A: Choice A deflects responsibility and may come off as defensive, not addressing the client's emotions directly.
C: Choice C shifts the focus away from the client's immediate distress and may not be well-received in the heat of the moment.
D: Choice D, while giving space, doesn't address the behavior directly and may not effectively address the client's emotions or the impact of their actions on the nurse.
An employee uses the defense mechanism of displacement when the boss openly disagrees with suggestions. What behavior would be expected from this employee?
- A. The employee assertively confronts the boss
- B. The employee leaves the staff meeting to work out in the gym
- C. The employee criticizes a coworker
- D. The employee takes the boss out to lunch
Correct Answer: C
Rationale: Displacement is a defense mechanism where emotions are redirected from the original source to a substitute target. In this case, the employee is likely to displace their anger from the boss onto a coworker by criticizing them. This behavior allows the employee to express their feelings indirectly.
A: Assertively confronting the boss does not align with displacement as it involves direct confrontation.
B: Leaving the meeting to work out in the gym is a form of avoidance and does not involve displacing emotions onto another target.
D: Taking the boss out to lunch is more of a conciliatory gesture and does not involve displacing negative emotions onto someone else.