A nurse is caring for a client whose partner recently died from an opioid overdose. The client tells the nurse, "Now, I volunteer for the local chapter of Narcotics Anonymous." The nurse should identify that the client is demonstrating which of the following defense mechanisms?

Repression

Displacement

Sublimation

Rationalization

Answer and Explanation

The Correct Answer is C

Choice A reason: Repression involves unconsciously blocking painful or unacceptable thoughts and feelings from awareness. In this case, the client is not avoiding or forgetting the loss but instead channeling energy into constructive activity. Therefore, repression does not apply.

Choice B reason: Displacement occurs when emotions are redirected from the original source to a safer substitute target. For example, expressing anger at a coworker instead of the true source of frustration. The client is not redirecting emotions but transforming them into positive action, so displacement is not correct.

Choice C reason: Sublimation is the defense mechanism where unacceptable impulses or painful emotions are transformed into socially acceptable and constructive behaviors. By volunteering for Narcotics Anonymous after the partner’s overdose, the client is channeling grief and potential maladaptive impulses into meaningful community service. This is a healthy and adaptive defense mechanism.

Choice D reason: Rationalization involves justifying or explaining away unacceptable feelings or behaviors with logical reasoning. The client is not making excuses or justifications but actively engaging in positive coping. Therefore, rationalization is not the correct mechanism.

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Correct Answer is C

Explanation

Choice A reason: Encouraging a client to gain 2.3 kg (5 lb) per week is unsafe and unrealistic. Rapid weight gain increases the risk of refeeding syndrome, electrolyte imbalance, and cardiac complications. The recommended goal is gradual weight gain of about 0.5 to 1 kg per week to ensure safety and sustainability.

Choice B reason: Weighing the client once per week is insufficient. Clients with anorexia nervosa require daily weights to closely monitor progress and detect dangerous fluctuations. Weekly weighing could miss critical changes in nutritional status.

Choice C reason: Monitoring the client for 1 hr after meals is correct because individuals with anorexia nervosa may attempt to purge or exercise excessively after eating. Close observation ensures food intake is retained and prevents compensatory behaviors, supporting nutritional rehabilitation.

Choice D reason: Allowing the client to choose meal times is inappropriate because it reinforces disordered eating patterns. Structured meal times are necessary to normalize eating habits and reduce avoidance behaviors.

A. Hallucinations. B. Agnosia. C. Bradycardia. D. Aphasia.

Correct Answer is A

Explanation

Choice A reason: Hallucinations are a common manifestation of delirium, especially when triggered by acute illness such as fever. Delirium is characterized by disturbances in attention, awareness, and cognition, often accompanied by perceptual disturbances like visual or auditory hallucinations.

Choice B reason: Agnosia, the inability to recognize objects or people, is more commonly associated with neurocognitive disorders such as dementia rather than acute delirium. While delirium affects cognition, agnosia is not a typical finding.

Choice C reason: Bradycardia is not a hallmark of delirium. Delirium is primarily a cognitive and perceptual disturbance, not a cardiac rhythm disorder. Bradycardia would suggest another underlying medical issue.

Choice D reason: Aphasia, a language disturbance, is more characteristic of stroke or other focal neurological disorders. Delirium may cause disorganized speech due to confusion, but not true aphasia.

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A nurse is caring for a client whose partner recently died from an opioid overdose. The client tells the nurse, "Now, I volunteer for the local chapter of Narcotics Anonymous." 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 creating a plan of care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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