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 C

Explanation

A. The client's heart rate has increased to 110/min is incorrect. While an increased heart rate can indicate pain, it can also be caused by other factors such as anxiety, dehydration, or fever. Heart rate alone is not the most specific or reliable indicator for the need for analgesia.

B. The client grimaces when changing positions is a possible sign of discomfort, but the level of pain cannot be accurately assessed from facial expressions alone. This may suggest mild to moderate pain but does not provide a clear numerical indication of the client's pain level.

C. The client reports pain as 7 on a scale of 0 to 10 is correct. The pain scale is a more direct and reliable measure of the client's pain experience. A rating of 7 indicates moderate to severe pain, which justifies the need for analgesic intervention.

D. The client demonstrates a decreased attention span could be related to pain or discomfort, but it may also result from other causes, such as fatigue, emotional stress, or medication side effects. This is not as definitive as a self-reported pain level.

A. Pain in the right upper abdomen B. Discomfort with urination C. Pain radiating to the jaw D. Increased abdominal discomfort prior to meals

Correct Answer is A

Explanation

A. Pain in the right upper abdomen is correct. Acute cholecystitis is the inflammation of the gallbladder, typically caused by gallstones blocking bile flow. This condition leads to severe right upper quadrant (RUQ) pain, often triggered by fatty meals and sometimes accompanied by nausea, vomiting, and fever.

B. Discomfort with urination is incorrect. Urinary discomfort is not associated with cholecystitis. This symptom is more indicative of urinary tract infections (UTIs) or kidney stones.

C. Pain radiating to the jaw is incorrect. Jaw pain is more characteristic of cardiac conditions, such as myocardial infarction (MI), rather than gallbladder inflammation.

D. Increased abdominal discomfort prior to meals is incorrect. Clients with cholecystitis typically experience more pain after meals, especially fatty foods, due to gallbladder contractions attempting to release bile.

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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

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Correct Answer is C

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Correct Answer is A

Explanation

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