A nurse is caring for a client who states, “I did not take my medication because my partner forgot to remind me.” The nurse should identify that the client is demonstrating which of the following defense mechanisms?

Rationalization

Projection

Repression

Regression

Answer and Explanation

The Correct Answer is B

Choice A reason: Rationalization involves justifying behavior with logical excuses, not blaming others. The client attributes their failure to their partner, which is projection, making this incorrect for the defense mechanism.

Choice B reason: Projection involves attributing one’s own shortcomings, like forgetting medication, to another person, such as the partner. The client blames their partner, making this the correct defense mechanism.

Choice C reason: Repression is unconsciously blocking distressing thoughts, not blaming others. The client openly acknowledges the missed medication, so this is incorrect for the observed behavior.

Choice D reason: Regression involves reverting to childish behaviors, not blaming others. The client’s statement reflects externalizing responsibility, fitting projection, making this incorrect for the defense mechanism.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason: Darkening the room may help but is less comprehensive than reducing all stimuli. Noise, light, and activity can exacerbate restlessness, so a broader approach is needed, making this incorrect.

Choice B reason: Applying restraints can increase agitation and injury risk in a restless client. Non-restrictive calming measures are preferred, making this incorrect for managing post-coma restlessness safely.

Choice C reason: Opioids may sedate but risk respiratory depression and mask neurological changes. Reducing stimuli is safer and addresses restlessness directly, making this incorrect for the care plan.

Choice D reason: Reducing stimuli, like noise and activity, calms the client emerging from a coma, preventing agitation. This aligns with TBI care to promote recovery, making it the correct intervention.

A. P: 50; R: 22; B/P: 140/60 B. P: 56; R: 20; B/P: 130/110 C. P: 60; R: 18; B/P: 126/96 D. P: 120; R: 16; B/P: 80/60

Correct Answer is A

Explanation

Choice A reason: Increasing ICP causes Cushing’s triad: bradycardia (P: 50), irregular respirations (R: 22), and widened pulse pressure (B/P: 140/60). These indicate brain compression, requiring immediate notification, making this the correct vital sign change.

Choice B reason: A pulse of 56 and B/P of 130/110 show hypertension but not widened pulse pressure. Respirations are mildly elevated, not irregular, making this less indicative of ICP than Cushing’s triad.

Choice C reason: P: 60, R: 18, and B/P: 126/96 are near normal, not reflecting Cushing’s triad. These changes are subtle and less concerning for acute ICP elevation, making this incorrect.

Choice D reason: P: 120 and B/P: 80/60 suggest shock, not ICP. Tachycardia and hypotension are opposite to Cushing’s triad, making this incorrect for indicating increasing intracranial pressure.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client who states, “I did not take my medication because my partner forgot to remind me.” The nurse should identify that the client is demonstrating which of the following defense mechanisms?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who had a traumatic brain injury and is emerging restlessly from a coma. Which of the following interventions should the nurse include in the plan?

Correct Answer is D

Explanation

A client has a head injury and is brought to the emergency department. The vital signs are P: 78; R: 16; B/P: 120/80. The change in this client’s vital signs that indicates increasing intracranial pressure (ICP) requiring notification of the practitioner is:

Correct Answer is A

Explanation

The client is scheduled for an electroencephalogram (EEG) to help diagnose a seizure disorder. Which pre-procedure teaching should the nurse exclude?

A nurse wants to improve their therapeutic communication by implementing bias-free language. Which of the following actions should the nurse take to provide bias-free language?

The nurse is at bedside with a client who started having a tonic-clonic seizure. Which of the following actions should the nurse implement first during the ictal stage?

The nurse is reviewing the different types of personality disorders and recognizes the following fall into the Cluster A Personality Disorders? (Select all that apply)

A nurse is caring for a client who has a mild traumatic brain injury (TBI). Which of the following manifestations should the nurse immediately report to the provider?

A nurse is performing a neurological assessment for a client who has head trauma. Which of the following assessments will give the nurse information about the function of the oculomotor cranial nerve?

A nurse in an acute mental health unit is admitting a client who has bipolar disorder. Which of the following findings supports the admitting diagnosis of acute mania?

A home-health nurse is assessing a client who has obsessive-compulsive disorder (OCD) and finds that the client demonstrates constant repetitive cleaning. The nurse knows that this behavior is an attempt to accomplish which of the following?