A client reports to the nurse about feeling upset because no family or friends have visited in two days. The client then begins to shout and toss small objects toward the nurse. Which defense mechanism should the nurse recognize the client is displaying?

Suppression.

Displacement.

Rationalization.

Conversion.

Answer and Explanation

The Correct Answer is B

Rationale:
A. Suppression: Suppression is the conscious effort to avoid thinking about distressing thoughts or feelings. The client is not consciously avoiding emotions; instead, the client is actively expressing anger.

B. Displacement: Displacement involves redirecting emotions or impulses from a threatening or unavailable target to a safer or more accessible one. The client is upset about the absence of family or friends but directs anger toward the nurse, a safer target, which is characteristic of displacement.

C. Rationalization: Rationalization involves creating logical or socially acceptable explanations to justify unacceptable feelings or behaviors. The client is not providing justifications but expressing anger outwardly.

D. Conversion: Conversion is the unconscious expression of psychological distress as physical symptoms. The client’s shouting and throwing objects reflect emotional expression, not somatic manifestations, so conversion is not occurring.

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"}}

Explanation

Rationale:

• Maintain strict bedrest: Strict bedrest is not required for an infant with measles who is hemodynamically stable and able to move independently. Activity should be allowed as tolerated to promote comfort and normal development. Forced immobility may increase irritability and distress. Rest is encouraged, but strict bedrest is unnecessary.

• Isolate until fifth day of rash: Measles is highly contagious and requires airborne isolation to prevent transmission. Clients are considered infectious from four days before to four days after rash onset, making isolation through the fifth day essential. Initiating and maintaining isolation protects other patients, caregivers, and healthcare staff. This intervention aligns with infection control guidelines for measles management.

• Apply loose-fitting clothing: Loose-fitting clothing helps reduce skin irritation and discomfort associated with the maculopapular rash. It also allows better heat dissipation in a febrile child, supporting temperature regulation. Tight clothing could worsen skin discomfort and increase irritability. Comfort-focused care is appropriate in viral illnesses like measles.

• Encourage soft, bland foods: The child has decreased appetite, nausea, and oral lesions consistent with Koplik spots, which can make chewing painful. Soft, bland foods reduce oral discomfort and support adequate nutritional intake. Maintaining nutrition aids recovery and prevents further fatigue. This intervention supports comfort and hydration without causing additional irritation.

• Restrict oral intake: Restricting oral intake increases the risk of dehydration, especially in a febrile infant with tachypnea. Adequate fluids are essential to maintain hydration and support metabolic demands during infection. Encouraging fluids is more appropriate than limiting intake.

A. Phenylketonuria. B. Adrenal insufficiency. C. Hypercortisolism. D. Diabetes mellitus.

Correct Answer is B

Explanation

Rationale:
A. Phenylketonuria: Phenylketonuria is a genetic metabolic disorder present from birth where the body cannot break down the amino acid phenylalanine, unrelated to glucocorticoid therapy or abrupt discontinuation. It is not a risk in this scenario.

B. Adrenal insufficiency: Abrupt cessation of glucocorticoids can suppress the hypothalamic-pituitary-adrenal (HPA) axis. Without tapering, the adrenal glands may not produce adequate endogenous cortisol, leading to adrenal insufficiency. Symptoms can include fatigue, hypotension, nausea, and risk of adrenal crisis.

C. Hypercortisolism: Hypercortisolism, or Cushing’s syndrome, results from prolonged high levels of cortisol. Stopping glucocorticoids would not cause hypercortisolism; rather, it creates a deficiency state.

D. Diabetes mellitus: While glucocorticoids can induce hyperglycemia, abrupt discontinuation does not directly cause diabetes. The client’s main risk is insufficient cortisol production rather than elevated blood glucose.

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A client reports to the nurse about feeling upset because no family or friends have visited in two days. The client then begins to shout and toss small objects toward the nurse. Which defense mechanism should the nurse recognize the client is displaying?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data For each nursing intervention, click to indicate whether the action is appropriate or not appropriate for this client. Each row must have only one response option selected.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"B"}}

Explanation

A male client informs the nurse he has suddenly stopped taking the glucocorticoid medication without consulting the healthcare provider. The nurse should recognize the client is at risk for developing which condition?

Correct Answer is B

Explanation

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