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 B
Explanation
Choice A reason: Protective eyewear is not required for MRI; removing transdermal patches prevents burns. Assuming eyewear is needed risks misinformation, potentially causing confusion, critical to avoid in ensuring accurate preparation and safety for clients undergoing MRI scans in diagnostic settings.
Choice B reason: Removing transdermal patches before an MRI prevents burns from metallic components, critical for client safety. This instruction ensures proper preparation, reducing injury risk, supporting safe imaging, and adhering to MRI safety protocols, essential for clients undergoing magnetic resonance imaging procedures.
Choice C reason: Tattoos are generally safe for MRI, though rare risks exist; patches are a greater concern. Assuming tattoos contraindicate MRI risks unnecessary restriction, potentially delaying diagnosis, critical to avoid in ensuring accurate preparation and access to imaging for clients with tattoos.
Choice D reason: Iodine allergy is relevant for CT contrast, not MRI, which uses gadolinium; patches are priority. Assuming iodine allergy contraindicates MRI risks misinformation, potentially delaying imaging, critical to prevent in ensuring proper preparation and safety for clients undergoing MRI scans.
Correct Answer is D
Explanation
Choice A reason: Urine output of 20 mL/hr is below the desired 30 mL/hr during magnesium sulfate therapy, indicating potential toxicity or renal issues, not a therapeutic effect. Absence of eclampsia is the goal. Monitoring for low output risks missing seizure prevention, critical for maternal safety in preeclampsia management.
Choice B reason: Fetal heart rate of 116/min is within normal (110-160/min) but not a direct therapeutic effect of magnesium sulfate, which prevents seizures. Absence of eclampsia is key. Assuming heart rate is the focus risks overlooking maternal neurological status, critical for ensuring seizure prevention in preeclampsia treatment.
Choice C reason: Blood pressure of 150/92 mm Hg, while elevated, is not the primary therapeutic effect of magnesium sulfate, which targets seizure prevention, not hypertension. Absence of eclampsia is priority. Focusing on blood pressure risks neglecting seizure monitoring, critical for maternal safety in preeclampsia management with magnesium.
Choice D reason: Absence of eclampsia (seizures) is the primary therapeutic effect of magnesium sulfate in preeclampsia, stabilizing neuronal excitability, preventing life-threatening convulsions. Monitoring this ensures maternal safety, critical for preventing neurological damage, supporting fetal well-being, and guiding therapy adjustments in high-risk obstetric care.
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