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?

Compensation

Sublimation

Regression

Suppression

Answer and Explanation

The Correct Answer is D

A.   Compensation involves overachieving in one area to make up for deficiencies in another area, which is not evident in the client's statement.
B.   Sublimation involves channeling unacceptable impulses into socially acceptable activities, which is not demonstrated in the client's statement.
C.   Regression involves reverting to an earlier stage of development in the face of stress, which is not evident in the client's statement.
D.   Suppression involves consciously avoiding or postponing dealing with a stressor, which aligns with the client's statement of delaying thinking about their diagnosis until after a significant event.

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Naxlex Comprehensive Predictor Exams

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

Explanation

A. Placing the client in a reclining chair is not recommended as it does not prevent wandering or falls and may even restrict movement leading to discomfort or pressure sores.
B. Putting locks at the top of doors can prevent the client from wandering outside, which reduces the risk of falls and getting lost, especially during the night.
C. Encouraging physical activity prior to bedtime can help in expending energy which may lead to better sleep and reduce restlessness and wandering at night.
D. Positioning the mattress on the floor can minimize injury from falls that may occur when the client attempts to get out of bed during the night.
E. Installing sensor devices on outside doors can alert the caregiver if the client attempts to leave the house, which is crucial for preventing wandering and potential falls.

A. Offer to talk with the caregiver about their feelings. B. Refer the caregiver to a local support group. C. Discuss relaxation techniques with the caregiver. D. Consult social services to explore counseling for the caregiver.

Correct Answer is A

Explanation

A. Offering to talk with the caregiver about their feelings provides immediate support and validation of their emotions. It allows the caregiver to express their concerns and stressors, which can help alleviate some of the caregiver's distress.
B. Referring the caregiver to a local support group is a helpful intervention but may not address the caregiver's immediate emotional needs. Offering immediate support by listening and empathizing is the first step.

C. Discussing relaxation techniques with the caregiver may be beneficial, but addressing the caregiver's emotional distress should take precedence.
D. Consulting social services to explore counseling for the caregiver is a valuable intervention, but offering immediate support by engaging in a conversation about their feelings is the most appropriate initial action.

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Naxlex Comprehensive Predictor Exams

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.)

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

Explanation

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?

Correct Answer is A

Explanation

A home health nurse is visiting a client who is recovering from coronary artery bypass surgery and reports experiencing stress. The nurse should determine that which of the following factors might interfere with the client's recovery?

A nurse is creating a plan of care for a client who has major depressive disorder. Which of the following interventions should the nurse include in the plan?

A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanisms is the client demonstrating?

A nurse is caring for a client who is receiving inpatient treatment for an eating disorder. The client states, "I just can't sleep soundly here because It's too noisy." Which of the following actions should the nurse take?

A nurse is reviewing the day 5 vital signs and nurses' 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.

A nurse is assessing the spiritual beliefs of a client. Which of the following client statements indicates spiritual distress?

A nurse is leading a grief support group for bereaved clients. Which of the following client statements should the nurse report to the provider as an indication of clinical depression?