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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Wearing gloves prevents nicotine absorption through the nurse’s skin during patch application, ensuring safety and preventing side effects like dizziness. This adheres to standard precautions, critical for occupational health, maintaining hygiene, and ensuring effective nicotine therapy for clients in smoking cessation programs.
Choice B reason: Removing the previous patch is correct but placing it in tissue is inadequate; it should be folded and disposed in a sharps container. Assuming tissue disposal is sufficient risks improper handling, potentially exposing others to nicotine, critical to avoid in safe patch management.
Choice C reason: Applying the patch within 1 hour of pouch removal is unnecessary; patches remain stable longer. Wearing gloves is priority. Assuming time restriction risks rushed application, potentially compromising technique, critical to prevent in ensuring safe and effective nicotine patch therapy for smoking cessation.
Choice D reason: Shaving hairy areas risks skin irritation; trimming is preferred before patch application. Wearing gloves is essential. Assuming shaving is correct risks skin damage, reducing patch adhesion, critical to avoid in ensuring proper application and effective nicotine delivery in smoking cessation therapy.
Correct Answer is D
Explanation
Choice A reason: Repositioning the NG tube is a later step; checking suction function is first, as equipment failure is a common cause of no drainage. Assuming repositioning is initial risks delaying simple fixes, potentially prolonging discomfort, critical to avoid in ensuring effective gastric decompression.
Choice B reason: Injecting air and aspirating is a troubleshooting step but follows checking suction equipment, which may resolve no drainage. Assuming air injection is first risks unnecessary intervention, potentially causing discomfort, critical to prevent in ensuring efficient NG tube management for gastric decompression.
Choice C reason: Instilling irrigation solution is a later step after confirming suction function, as equipment issues are more common. Assuming irrigation is first risks clogging or discomfort, critical to avoid in ensuring proper NG tube function and effective gastric decompression in clients with non-draining tubes.
Choice D reason: Checking suction equipment function is the first step for a non-draining NG tube, as equipment failure is a common issue, easily corrected. This ensures effective decompression, critical for preventing gastric distention, supporting client comfort, and guiding further troubleshooting in managing NG tube care.
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