A nurse is caring for a client who has a new diagnosis of metastatic lung cancer. The client states, "I can't think about that until after my first grandchild is born next week." The nurse should identify the client's statement as indicating the maladaptive use of which of the following defense mechanisms?

Sublimation

Compensation

Suppression

Regression

Answer and Explanation

The Correct Answer is C

A.   Sublimation involves channeling unacceptable impulses into socially acceptable activities, which is not
demonstrated by the client’s statement.
B.   Compensation involves making up for a perceived deficiency in one area by excelling in another area.
This is not relevant to the client’s statement.
C.   Suppression is a defense mechanism where an individual consciously avoids thinking about something distressing. The client is consciously postponing thoughts about their cancer diagnosis until after a personal event.
D.   Regression involves reverting to an earlier stage of development in response to stress, which is not
reflected in the client’s attempt to delay thinking about the diagnosis.

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Correct Answer is A

Explanation

A. Remaining with the client after meals helps provide emotional support and prevents purging behaviors that may occur in individuals with eating disorders like binge eating disorder.
B. Regular monitoring of weight is important, but frequent weighing may contribute to anxiety and focus on weight rather than addressing the underlying disorder.
C. Offering snacks on demand could encourage disordered eating patterns and may not help in establishing regular eating habits.
D. While involving the client in meal planning can be helpful for certain eating disorders, the focus should be on establishing a structured, balanced eating plan and addressing emotional needs rather than allowing unstructured eating.

A. Assess the client's need for toileting every 15 min. B. Ask the provider to renew the prescription every 8 hr. C. Have a staff member check on the client every 30 min. D. Offer hydration and nutrition to the client every 2 hr.

Correct Answer is A

Explanation

A. The nurse should assess the client’s need for toileting regularly, as restricted movement can increase the risk of discomfort and physical harm. Monitoring this every 15 minutes is recommended for ensuring the client's basic needs are met.
B. Physical restraint prescriptions should be renewed at intervals that are consistent with the facility’s
policies, but every 8 hours is typically too long. A more frequent reassessment should occur.
C. Clients in restraints should be monitored more frequently than every 30 minutes to ensure their safety and well-being, especially in terms of physical comfort and circulation.
D. Offering hydration and nutrition every 2 hours may not be necessary if the client is receiving fluids and food regularly, but they should be monitored more frequently for other immediate needs.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a binge eating disorder. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for an adult client who has been placed in physical restraints due to aggressive behavior. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a group of clients on a mental health unit. For which of the following clients is the nurse considered a mandated reporter to the appropriate agency?

A nurse is conducting an admission interview with a client who is experiencing mania. Which of the following findings should the nurse report to the provider?

A nurse is developing a plan of care for a client who has paranoid personality disorder. Which of the following actions should the nurse include in the plan?

A nurse is caring for a client who is experiencing alcohol withdrawal. Exhibits A nurse is planning care for a client who has alcohol use disorder. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

A nurse is caring for a client who states, "Things will never work out." Which of the following responses should the nurse make?

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