A nurse is assessing a client whose partner is receiving hospice care and is dying. The client states, “I should start planning the trip that we want to take.” Which of the following ego-defense mechanisms is the client expressing?

Dissociation

Denial

Regression

Displacement

Answer and Explanation

The Correct Answer is B

Choice A Reason:

Dissociation is a defense mechanism where a person disconnects from their thoughts, feelings, or sense of identity. It often occurs in response to trauma or extreme stress, allowing the individual to distance themselves from the reality of the situation. In this case, the client is not showing signs of dissociation, such as feeling detached from reality or experiencing memory gaps. Instead, they are avoiding the reality of their partner’s condition.

Choice B Reason:

Denial is a defense mechanism where a person refuses to accept the reality of a situation to avoid dealing with painful emotions. The client’s statement about planning a trip despite their partner’s terminal condition indicates that they are not acknowledging the severity of the situation. This refusal to accept reality helps them cope with the emotional distress associated with their partner’s impending death.

Choice C Reason:

Regression involves reverting to behaviors from an earlier stage of development when faced with stress. This might include actions like thumb-sucking, bed-wetting, or other childlike behaviors. The client’s statement does not indicate a return to earlier developmental behaviors but rather a refusal to accept the current reality.

Choice D Reason:

Displacement is a defense mechanism where negative emotions are redirected from their original source to a less threatening target. For example, someone might take out their frustration with their boss on a family member. In this scenario, the client is not redirecting their emotions but rather avoiding the reality of their partner’s condition.

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Correct Answer is B

Explanation

Choice A reason:

Lowering the head of the client’s bed to 15 degrees can help facilitate the drainage of the NG tube. This position uses gravity to assist in the movement of gastric contents through the tube. However, it is not the most effective method to address the issue of the NG tube not draining. This action might be more appropriate for other clinical scenarios, such as preventing aspiration, but it is not the primary intervention for a non-draining NG tube.

Choice B reason:

Injecting 10 mL of air into the vent lumen is a common technique used to clear an obstruction in the NG tube. This action can help dislodge any blockages that may be preventing the tube from draining properly. By injecting air, the nurse can ensure that the tube is patent and functioning correctly. This method is often recommended in clinical guidelines for managing NG tube blockages.

Choice C reason:

Placing the NG tube to high suction is not recommended as it can cause damage to the gastric mucosa and lead to complications such as bleeding or ulceration. High suction can create excessive negative pressure, which can harm the delicate tissues of the stomach lining. Therefore, this action is not appropriate for managing a non-draining NG tube and should be avoided.

Choice D reason:

Connecting the air vent to the suction is incorrect and can lead to malfunction of the NG tube. The air vent, also known as the pigtail, is designed to allow air to enter the stomach and prevent the tube from adhering to the gastric mucosa. Connecting it to suction would negate its purpose and could cause the tube to become blocked or damaged. This action is not recommended in any clinical guidelines for NG tube management.

A. The client speaks the same language as the nurse. B. The client signed in the nurse’s presence. C. The client was not coerced. D. The client has legal authority to do so. E. The client does not have a mental health condition.

Correct Answer is ["B","C","D"]

Explanation

Choice A Reason:

The requirement that the client speaks the same language as the nurse is not a standard criterion for informed consent. While effective communication is crucial, the presence of an interpreter can facilitate understanding if there is a language barrier. The nurse’s signature does not confirm the language spoken by the client.

Choice B Reason:

The nurse’s signature on the informed consent form confirms that the client signed the document in the nurse’s presence. This is a standard practice to ensure that the consent was given voluntarily and that the client was present at the time of signing. It helps in verifying the authenticity of the consent.

Choice C Reason:

The nurse’s signature also confirms that the client was not coerced into signing the consent form. Informed consent must be given voluntarily, without any form of pressure or coercion. This ensures that the client’s decision is made freely and with full understanding of the procedure or treatment.

Choice D Reason:

The nurse’s signature confirms that the client has the legal authority to give consent. This means that the client is of legal age and has the mental capacity to understand the information provided and make an informed decision. It is essential to ensure that the client is legally competent to consent to the treatment or procedure.

Choice E Reason:

The requirement that the client does not have a mental health condition is not a standard criterion for informed consent. Clients with mental health conditions can still provide informed consent if they have the capacity to understand the information and make a decision. The nurse’s signature does not confirm the mental health status of the client.

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A nurse is assessing a client whose partner is receiving hospice care and is dying. The client states, “I should start planning the trip that we want to take.” Which of the following ego-defense mechanisms is the client expressing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has an NG tube set to low-intermittent suction for gastric decompression. The nurse observes that the NG tube is not draining. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A staff nurse is teaching a newly hired nurse how to complete an informed consent document for a client. The staff nurse should include that the nurse’s signature on the form confirms which of the following requirements? (Select all that apply.)

Correct Answer is ["B","C","D"]

Explanation

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