A nurse is caring for an adolescent who states, "I joined the track and field team, so I won't argue with my brothers anymore." The nurse should identify that the client is using which of the following defense mechanisms?

Denial

Sublimation

Regression

Repression

Answer and Explanation

The Correct Answer is B

A. Denial is incorrect. Denial involves refusing to acknowledge reality or a distressing situation, which is not evident in this scenario. The adolescent is aware of the conflict and has chosen a constructive way to address it.

B. Sublimation is correct. Sublimation is the process of channeling unacceptable impulses (such as frustration or aggression) into socially acceptable activities (such as sports or creative pursuits). By joining the track and field team instead of arguing with his brothers, the adolescent is redirecting energy into a positive outlet.

C. Regression is incorrect. Regression occurs when an individual reverts to an earlier stage of development in response to stress. Examples include an older child suddenly sucking their thumb or having temper tantrums. The adolescent in this scenario is demonstrating maturity, not regression.

D. Repression is incorrect. Repression involves unconsciously blocking distressing thoughts or emotions from awareness. The adolescent is not avoiding or forgetting about the conflict but is instead managing it through physical activity.

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Correct Answer is D

Explanation

A. Copy of the client's advance directives: While advance directives are important documents, they are typically filed with the medical record, not specifically included in postmortem documentation. The focus for postmortem documentation is on the body and relevant events surrounding the death.

B. Cause of the client's death.: The cause of death is typically recorded in the official death certificate, which is not part of postmortem nursing documentation. The nurse should not make a diagnosis about the cause of death but may note any relevant findings.

C. Last set of the client's vital signs: Vital signs taken at the time of death may be noted as part of the clinical documentation, but they are not specifically part of postmortem documentation. The postmortem documentation should focus on observations regarding the body and its condition.

D. Location of the identification tag on the client’s body: The nurse should document the location of identification tags on the body to ensure proper identification and to prevent confusion or errors in postmortem care. This is an important detail in postmortem documentation.

A. Tinnitus with ear pain B. Diplopia C. Hyperreflexia D. Skin rash with fever

Correct Answer is D

Explanation

A. Tinnitus with ear pain: While tinnitus can be a side effect of some medications, it is not associated with Stevens-Johnson syndrome (SJS). This symptom is more common with other medications or conditions, like aspirin or certain antibiotics, but not allopurinol.

B. Diplopia: Diplopia (double vision) is not a common sign of Stevens-Johnson syndrome. This symptom could be related to other conditions but is not characteristic of SJS.

C. Hyperreflexia: Hyperreflexia is not a typical manifestation of Stevens-Johnson syndrome. While neurological symptoms may sometimes occur, they are not central to the diagnosis of SJS.

D. Skin rash with fever: A skin rash with fever is a classic early sign of Stevens-Johnson syndrome. It is a potentially life-threatening reaction to certain medications, including allopurinol, and requires immediate medical attention. The rash often begins with a mild erythema, which may progress to blistering and sloughing of the skin.

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A nurse is caring for an adolescent who states, "I joined the track and field team, so I won't argue with my brothers anymore." The nurse should identify that the client is using which of the following defense mechanisms?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is completing postmortem documentation for a client. Which of the following information should the nurse include in the documentation?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a client who is taking allopurinol about the risk for developing Stevens-Johnson syndrome. For which of the following manifestations should the nurse instruct the client to monitor and report?

Correct Answer is D

Explanation

A charge nurse in a long-term care facility is discussing ethical theories with a group of newly licensed nurses. Which of the following statements should the charge nurse identify as an indication that a newly licensed nurse understands utilitarianism?

A nurse is collecting data from a client who is receiving IV therapy. The nurse suspects fluid infiltration. Which of the following findings should the nurse expect at the insertion site?

A nurse is observing an assistive personnel (AP) take a client's tympanic temperature. Which of the following actions should the nurse identify as an indication that the AP understands how to perform the procedure?

A nurse is discussing risk factors for child abuse with members of a parenting group. The nurse should identify which of the following findings as a characteristic of perpetrators of child abuse?

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