A nurse is caring for a client who has a new diagnosis of chronic stress. Which of the following findings should the nurse recognize as a manifestation of rationalization?

The client ignores the nurse during the discussion about their diagnosis.

The client states, “I only act this way because my partner makes me so angry.”

The client refuses to accept treatment for their diagnosis.

The client calls the office multiple times per day to speak with their provider.

Answer and Explanation

The Correct Answer is B

Choice A reason: Ignoring the nurse reflects avoidance, not rationalization, where clients justify behaviors, like blaming a partner. Assuming ignoring is rationalization risks misidentifying coping, potentially missing stress management needs, critical to avoid in supporting clients with chronic stress diagnoses.

Choice B reason: Stating behavior is due to a partner’s actions is rationalization, justifying stress responses to avoid responsibility. Recognizing this is critical for addressing maladaptive coping, guiding therapeutic interventions, and supporting healthier stress management strategies in clients with chronic stress diagnoses.

Choice C reason: Refusing treatment reflects denial, not rationalization, where clients provide excuses like blaming others. Assuming refusal is rationalization risks misinterpreting coping, potentially delaying intervention, critical to prevent in addressing chronic stress and promoting treatment acceptance in clients.

Choice D reason: Frequent calls reflect anxiety or dependency, not rationalization, where clients justify behaviors, like blaming others. Assuming calls are rationalization risks missing emotional needs, critical to avoid in ensuring proper stress management and support for clients with chronic stress diagnoses.

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Correct Answer is B

Explanation

Choice A reason: Discussing preferences for repositioning schedules is secondary to assessing physical ability in stroke clients, who may have hemiplegia. Evaluating ability ensures safety. Assuming preferences are priority risks unsafe repositioning, potentially causing falls, critical to avoid in ensuring safe mobility and care for stroke patients.

Choice B reason: Evaluating the client’s ability to assist with repositioning is critical post-stroke to assess motor function, ensuring safe technique and preventing injury. This informs whether assistive devices or additional staff are needed, essential for reducing fall risk, promoting recovery, and tailoring care to the client’s physical capacity.

Choice C reason: Repositioning without assistive devices is unsafe for stroke clients with potential weakness or paralysis, risking falls or strain. Evaluating ability is priority. Assuming no devices are needed risks injury, critical to prevent in ensuring safe handling, supporting recovery, and maintaining safety in stroke rehabilitation care.

Choice D reason: Raising side rails ensures safety but is secondary to evaluating the client’s ability to assist, which guides repositioning technique. Assuming rails are the first step risks overlooking physical capacity, potentially leading to unsafe repositioning, critical to avoid in preventing falls and ensuring safe care for stroke clients.

A. Speech-language pathologist. B. Occupational therapist. C. Respiratory therapist. D. Social worker.

Correct Answer is A

Explanation

Choice A reason: A speech-language pathologist assesses swallowing difficulties, recommending safe feeding techniques for dysphagia, critical for preventing choking and aspiration in older adults. This referral ensures tailored interventions, essential for nutritional safety, reducing pneumonia risk, and supporting quality of life in long-term care settings.

Choice B reason: Occupational therapists address functional skills, not primarily swallowing, which is managed by speech-language pathologists for dysphagia. Assuming their role risks delayed swallowing assessment, potentially increasing choking risk, critical to avoid in ensuring safe eating for older adults in long-term care facilities.

Choice C reason: Respiratory therapists manage breathing issues, not swallowing difficulties, which require a speech-language pathologist for dysphagia. Assuming their involvement risks missing specialized swallowing care, potentially leading to aspiration, critical to prevent in ensuring safe nutrition for older adults with choking risks.

Choice D reason: Social workers address psychosocial needs, not swallowing issues, managed by speech-language pathologists for dysphagia. Assuming their role risks neglecting physical swallowing assessment, increasing choking or aspiration risk, critical to avoid in ensuring safe meal management for older adults in long-term care.

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A nurse is caring for a client who has a new diagnosis of chronic stress. Which of the following findings should the nurse recognize as a manifestation of rationalization?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse in a long-term care facility is managing the care of an older adult client who has difficulty swallowing and occasional choking during meals. The nurse should initiate a referral to which of the following members of the interprofessional care team?

Correct Answer is A

Explanation

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