A nurse is caring for a client who states, "I smoke because I have a lot of anxiety." The nurse should recognize the client's statement as which of the following defense mechanisms?
Projection
Sublimination
Rationalization
Dissociation
The Correct Answer is C
A. Projection: Projection involves attributing one’s own undesirable feelings or thoughts onto others. This is not applicable here, as the client is not projecting their behavior onto someone else.
B. Sublimation: Sublimation is the process of channeling negative or unacceptable impulses into socially acceptable activities. Smoking due to anxiety is not an example of channeling impulses into a productive or acceptable activity.
C. Rationalization: Rationalization is a defense mechanism where a person justifies or makes excuses for their behavior or feelings. In this case, the client is justifying smoking as a way to manage anxiety, which is a classic example of rationalization.
D. Dissociation: Dissociation involves a detachment from reality or a separation of thoughts, identity, or consciousness, typically as a coping mechanism in response to trauma or stress. It is not applicable in this situation, where the client is not detaching from reality.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. The Emergency Medical Treatment and Active Labor Act requires that emergency care be provided regardless of the client’s behavior, as long as the client is seeking treatment for an emergency medical condition.
B. EMTALA requires that a client receive a medical screening and stabilization before being transferred, regardless of whether the condition is terminal. A terminal diagnosis does not justify transferring a client without stabilization first.
C. EMTALA prohibits discrimination based on a client’s ability to pay. A client cannot be transferred or discharged from an emergency department based on their inability to pay for services.
D. EMTALA requires that a client must be stabilized before being transferred to another facility. This ensures that the client is not placed at risk by the transfer, and the new facility is prepared to manage their care appropriately.
Correct Answer is D
Explanation
A. Oral temperature 37.4°C (99.3°F): This is a low-grade fever and is generally not concerning unless it increases or persists. It could be related to the body’s response to surgery but does not require immediate reporting to the provider.
B. BP 130/84 mm Hg: This is a normal blood pressure for most adults and does not indicate an issue. There is no immediate concern for the nurse to report this to the provider.
C. Heart rate 88/min: A heart rate of 88 beats per minute is within normal range for an adult and does not require reporting to the provider.
D. Respiratory rate 10/min: A respiratory rate of 10/min is significantly below the normal range for an adult (12-20 breaths per minute) and could indicate respiratory depression, a common side effect of opioid analgesics. This is a serious finding and should be reported to the provider immediately for further evaluation and intervention.
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