Nokea
Your client in crisis is detaching from self. Which psychological ego defense mechanism is this client most likely using?
- A. Displacement
- B. Sublimation
- C. Dissociation
- D. Reaction formation
Correct Answer: C
Rationale: Dissociation is the defense mechanism where a person detaches from their sense of self or reality to cope with overwhelming stress or trauma, which aligns with the client's behavior.
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The nurse is caring for a client with a history of seizures. Which precaution should be implemented?
- A. Keep the bed in the highest position.
- B. Ensure suction equipment is at the bedside.
- C. Allow the client to ambulate without assistance.
- D. Remove all padded side rails.
Correct Answer: B
Rationale: Suction equipment is essential to maintain airway patency during a seizure, a critical safety precaution.
The nurse is planning a program about women's health and cancer prevention for a community health fair. The nurse should include information about? Select all that apply.
- A. Regular self-exams of the breast and vulva are important self-care activities.
- B. Cancer can be prevented by removing precancerous lesions of the vulva, cervix, or endometrium.
- C. Girls, age 11 to 12, should receive immunization for human papilloma virus (HPV) to prevent cervical cancer.
- D. Smoking cessation reduces the risk of cervical cancer.
- E. There is limited evidence that cancer in women is inherited.
Correct Answer: A,B,C
Rationale: Self-exams, removal of precancerous lesions, and HPV vaccination are key prevention strategies. Smoking cessation reduces lung cancer risk, not cervical. Some cancers have genetic links.
You are running a caregiver support group for those who are caring for a person with impaired cognition related to Alzheimer's disease. You are planning a session on the stages of Alzheimer's disease, its progression and some useful helpful tips for these participating care givers. Which of the following elements should you include in this session?
- A. According to the Global Deterioration Scale, clients in the first stage of Alzheimer's disease tend to cover up their failing abilities
- B. According to the Reisberg Scale, clients in the first stage of Alzheimer's disease tend to cover up their failing abilities
- C. According to the Global Deterioration Scale, clients in the third stage of Alzheimer's disease tend to cover up their failing abilities
- D. According to the Reisberg Scale, clients in the fourth stage of Alzheimer's disease tend to cover up their failing abilities
Correct Answer: B
Rationale: The Reisberg Scale (Global Deterioration Scale) indicates that in the first stage, individuals with Alzheimer's may cover up their failing abilities, which is an important point to include for caregivers to understand early disease behaviors.
A nurse discusses with parents the procedures that will be performed on their neonate immediately after delivery. The nurse determines that the instructions have been understood when the client states that what will be done to the neonate first?
- A. The neonate will be suctioned.
- B. The neonate will be dried and stimulated.
- C. The neonate will be given oxygen.
- D. The neonate's umbilical cord will be cut.
Correct Answer: A
Rationale: Suctioning the neonate's airway is the first priority to ensure a clear airway and promote breathing immediately after delivery.
A client with a history of gout is admitted with joint swelling. The nurse should include which of the following in the plan of care?
- A. Apply warm compresses to affected joints.
- B. Encourage a high-purine diet.
- C. Administer indomethacin as prescribed.
- D. Restrict fluid intake.
Correct Answer: C
Rationale: Indomethacin reduces inflammation and pain in acute gout attacks.