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?

Suppression

Compensation

Regression

Sublimation

Answer and Explanation

The Correct Answer is A

Choice A reason:
Suppression is a conscious defense mechanism where an individual intentionally avoids thinking about disturbing thoughts or feelings. In this case, the client is choosing to delay addressing the reality of their diagnosis until after a significant family event. This can be seen as a temporary coping strategy to manage overwhelming emotions, but it may become maladaptive if overused or if it prevents the client from seeking necessary treatment and support.

Choice B reason:
Compensation involves overachieving in one area to make up for deficiencies in another. The client's statement does not suggest that they are trying to compensate for their illness by excelling in other areas of life; rather, they are postponing the emotional processing of their diagnosis.

Choice C reason:
Regression is a return to earlier stages of development and coping strategies, often under stress. The client's statement does not indicate a regression to more childlike behaviors or earlier developmental stages.

Choice D reason:
Sublimation is a way of channeling unacceptable impulses into socially acceptable actions. The client's statement does not reflect the use of sublimation, as they are not redirecting their feelings about the diagnosis into a different, more acceptable outlet.

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

Explanation

Choice A: Client reports limiting alcohol consumption
While reporting a reduction in alcohol consumption is a positive sign, it is not as strong an indicator of progress as actual participation in structured treatment programs like group therapy. Self-reported data can sometimes be unreliable, especially in individuals with a history of substance use disorders.
Choice B: Participation in group therapy
Participation in group therapy is a significant indicator of progress. Group therapy provides a supportive environment where clients can share experiences, gain insights, and receive encouragement from peers. It also helps in building coping strategies and reducing feelings of isolation.
Choice C: Appetite
Improvement in appetite is a good indicator of physical recovery and overall well-being. Alcohol use disorder often leads to poor nutrition and weight loss, so an increase in appetite suggests that the client’s body is beginning to recover and that they are likely consuming more nutritious food.
Choice D: Cognition
Improved cognition indicates that the client is recovering from the neurological effects of alcohol intoxication. This includes better clarity of thought, improved memory, and the ability to respond coherently to questions. Cognitive recovery is crucial for the client to engage effectively in therapy and other treatment activities.
Choice E: Vital signs
Stabilized vital signs are a clear indicator of physical recovery. On admission, the client had a high blood
Choice F: Movement through the stages of grief
While moving through the stages of grief is important for emotional recovery, it is a more subjective measure and can vary greatly among individuals. It is not as directly measurable as the other indicators listed.

A. Assist the client to ambulate for the first time following the procedure. B. Check the client's condition after the procedure. C. Witness the client's signature on the consent for the procedure. D. Give the client atropine 30 minutes before the procedure.

Correct Answer is A

Explanation

Choice A reason:
Assisting the client to ambulate for the first time following the procedure is a task that can be delegated to assistive personnel (AP). This task involves helping the client with mobility, which is within the scope of practice for APs. They are trained to assist with activities of daily living, including ambulation, under the supervision of a registered nurse.

Choice B reason:
Checking the client's condition after the procedure is a critical task that requires clinical judgment and assessment skills. This task should be performed by a registered nurse (RN) who can evaluate the client's vital signs, level of consciousness, and overall condition to identify any potential complications.

Choice C reason:
Witnessing the client's signature on the consent for the procedure is a legal responsibility that should be carried out by a registered nurse or another licensed healthcare provider. This task ensures that the client has given informed consent and understands the procedure, risks, and benefits.

Choice D reason:
Administering atropine 30 minutes before the procedure is a medication administration task that requires knowledge of pharmacology and the ability to monitor for adverse reactions. This task should be performed by a registered nurse or another licensed healthcare provider.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the day 5 vital signs and nurse’s notes. Exhibits A nurse is evaluating the client’s response to treatment. Select the 4 findings that indicate the client is progressing with their plan of care.

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

Explanation

A nurse is caring for a client who is undergoing electroconvulsive therapy. Which of the following tasks should the nurse delegate to an assistive personnel?

Correct Answer is A

Explanation

A nurse is caring for a client who has been taking quetiapine for 1 week and reports dizziness. The client asks the nurse if the dizziness indicates an allergic reaction to the medication. Which of the following responses should the nurse make?

A nurse is initiating the plan of care for a client who has anorexia nervosa. Exhibits Complete the following sentence by using the lists of options. The nurse should first address the client’s dropdown followed by the client’s dropdown

A nurse observes the caregiver of a client who has Alzheimer's disease throwing magazines on the floor and crying. Which of the following actions should the case manager take first?

A nurse in a mental health facility is caring for a group of clients. After assessing the clients, which of the following clients requires an update to their plan of care to ensure client safety?

A nurse is providing teaching to the caregiver of an older adult client who has Alzheimer's disease and is being cared for at home. The client wanders at night and has a history of previous falls. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

A nurse in a mental health facility is admitting a client. Exhibits A nurse is caring for a client who was admitted for alcohol use disorder. Which of the following findings require follow-up by the nurse? Select all that apply.

A nurse is providing teaching about self-care behaviors to a client who has major depressive disorder. Which of the following statements by the client indicates an understanding of the teaching?

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?