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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. "You can take a stool softener to prevent constipation." is correct. After a retinal detachment repair, clients should avoid straining during bowel movements, as increased intracranial pressure could affect the healing eye. Taking a stool softener is a helpful preventive measure to avoid constipation.

B. "You can remove your eye patch during the day." is incorrect. The eye patch should typically be worn continuously to protect the eye and support healing. The surgeon's specific instructions should be followed regarding when the patch can be removed.

C. "You should bend from the waist to pick up objects." is incorrect. After retinal surgery, clients should avoid bending from the waist as this can increase intraocular pressure, potentially compromising the surgical repair. Instead, clients should use proper body mechanics and bend at the knees.

D. "You can apply a warm, moist compress to your forehead to reduce pain." is incorrect. Applying a warm compress to the forehead is not typically recommended following a retinal repair. Clients should follow the specific post-operative instructions from the surgeon, which may include cold compresses or other methods of managing discomfort.

A. Have the client point his toes before inserting his foot into the stocking. B. Remove the stockings once every 24 hr. C. Elevate the client's legs for 5 min prior to applying the stockings. D. Roll the top of the stocking down so it fits snugly above the client's calf

Correct Answer is C

Explanation

A. Having the client point his toes before inserting his foot into the stocking is incorrect. The nurse should instruct the client to keep the foot in a neutral position to avoid unnecessary pressure on the toes or veins.

B. Removing the stockings once every 24 hr is incorrect. Antiembolic stockings should typically be removed and reapplied at least once per shift to allow for skin assessment and hygiene. They should not remain on for 24 hours continuously.

C. Elevating the client's legs for 5 min prior to applying the stockings is correct. Elevating the legs helps promote venous return by reducing swelling in the lower extremities. This makes the application of antiembolic stockings more effective and more comfortable for the client.

D. Rolling the top of the stocking down so it fits snugly above the client's calf is incorrect. The stockings should be applied smoothly and without folds to avoid restricting circulation. The top should not be rolled down as it can create pressure points

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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 assisting with discharge teaching for a client who is postoperative following the repair of a detached retina. Which of the following instructions should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is applying antiembolic stockings for a client who is postoperative. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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

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A nurse is giving change-of-shift report on a group of clients. Which of the following statements should the nurse make? (Select all that apply.)

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A nurse is reinforcing teaching with a client who is scheduled to have a colonoscopy in 1 week. Which of the following client statements indicates an understanding of the teaching?

A nurse is assisting with the care of a group of clients. Which of the following actions should the nurse take to manage her time effectively? (Select all that apply.)