A nurse assesses a confused older adult. The nurse experiences sadness and reflects, “The patient is like one of my grandparents… so helpless.” What feelings does the nurse describe?

Defensive coping reaction

The presence of countertransference

The presence of transference

Catastrophic reaction

Answer and Explanation

The Correct Answer is B

Choice A reason: Defensive coping involves mechanisms like denial to manage stress, not personal emotional connections to a patient. The nurse’s sadness reflects personal feelings, not a defense against anxiety. This term does not apply to the nurse’s emotional response to the patient’s condition or perceived helplessness.

Choice B reason: Countertransference occurs when a nurse projects personal feelings, like sadness, onto a patient due to similarities with personal experiences (e.g., grandparents). This emotional response can influence care if not managed, as it stems from the nurse’s unresolved feelings, making it the accurate description of the situation.

Choice C reason: Transference involves the patient projecting feelings onto the nurse, not the nurse’s emotions about the patient. The scenario describes the nurse’s feelings, not the patient’s, making transference inapplicable. The nurse’s sadness reflects personal emotional involvement, not a patient-driven dynamic.

Choice D reason: Catastrophic reaction refers to a patient’s exaggerated emotional response to stress, often in dementia, not the nurse’s feelings. The nurse’s sadness is a personal emotional reaction, not a patient behavior, making this term irrelevant to the described situation of the nurse’s emotional reflection.

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Correct Answer is A

Explanation

Choice A reason: A 201 status indicates voluntary admission to a mental health facility, where the client can request discharge by signing a withdrawal form, typically with a 72-hour notice period. This matches the client’s statement, as voluntary patients retain control over their discharge, consistent with mental health laws.

Choice B reason: A 303 status involves extended involuntary commitment for ongoing treatment, typically after a court hearing. It does not allow self-initiated discharge by signing a form, as the client’s statement suggests, making this status incompatible with the described ability to request withdrawal.

Choice C reason: A 302 status is an involuntary commitment for imminent danger, requiring medical or legal approval for discharge, not a simple request form. The client’s ability to sign for withdrawal indicates voluntary status, making 302 incorrect for this scenario.

Choice D reason: A 301 status is not a standard term in mental health commitment laws (e.g., Pennsylvania’s Mental Health Procedures Act). The client’s ability to request discharge aligns with voluntary (201) status, not an undefined or involuntary category, making this option incorrect.

A. Hyperkalemia B. Urine output of 2000 mL in 24 hours C. Tachycardia D. Tenting of the skin

Correct Answer is A

Explanation

Choice A reason: In the oliguric phase of AKI, kidney function is severely impaired, reducing potassium excretion. This leads to hyperkalemia, which disrupts cardiac electrical activity, potentially causing life-threatening arrhythmias or cardiac arrest. Elevated potassium levels are a hallmark of this phase due to decreased glomerular filtration rate and impaired tubular secretion.

Choice B reason: Urine output of 2000 mL in 24 hours indicates polyuria, characteristic of the recovery phase of AKI, not the oliguric phase, where output is typically less than 400 mL/day. High urine output suggests restored renal function, which is not expected in the oliguric phase, where kidneys fail to filter adequately.

Choice C reason: Tachycardia may occur in AKI due to fluid overload causing increased cardiac workload or electrolyte imbalances like hyperkalemia affecting heart rhythm. However, it is a secondary symptom and less specific than hyperkalemia, which directly results from impaired renal excretion and poses a more immediate risk to cardiac function.

Choice D reason: Tenting of the skin indicates dehydration, which may precede AKI but is not typical in the oliguric phase, where fluid retention is more common due to reduced urine output. Fluid overload leads to edema, not dehydration, making skin tenting an unlikely finding in this phase of AKI.

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A nurse assesses a confused older adult. The nurse experiences sadness and reflects, “The patient is like one of my grandparents… so helpless.” What feelings does the nurse describe?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client states, “I understand that in order to leave, I must sign a request to withdraw from treatment.” What is the client’s legal status?

Correct Answer is A

Explanation

The nurse is caring for a client who is in the oliguric phase of acute kidney injury (AKI). During this phase of AKI, the nurse might anticipate which of the following findings?

Correct Answer is A

Explanation

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