Exhibits

Click to specify which client statement or behaviors is most likely associated with each of the listed defense mechanisms. Some statements or behaviors may be consistent with more than one mechanism. Each column must have at least one response selected.

The client seems unemotional when talking about needing to rebuild her house.

The client says that she sometimes forgets why she is in the hospital.

The client discusses moving to Hawaii instead of returning to rebuild her house.

The client is frightened that the hospital will burn down.

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"B"}}

Client Statement: A. The client seems unemotional when talking about needing to rebuild her house.

Suppression fits here because the client appears detached or unemotional when discussing the significant emotional task of rebuilding her house after it collapsed. This suggests a deliberate effort to suppress or minimize the emotional impact of the situation.

Client Statement: C. The client discusses moving to Hawaii instead of returning to rebuild her house.

The client's discussion of moving to Hawaii instead of facing the reality of rebuilding her house reflects a form of fantasy. It suggests a retreat into an idealized scenario (moving to a distant, idyllic location) to avoid dealing directly with the trauma and stress associated with rebuilding her home.

Client Statement: B. The client says that she sometimes forgets why she is in the hospital.

Isolation can be inferred here because the client's statement about forgetting why she is in the hospital may indicate a psychological distancing or detachment from the traumatic events that led her there. It suggests a coping mechanism where she separates her emotional distress (related to the house collapse) from the practical reality of being hospitalized and receiving treatment.

Client Statement: D. The client is frightened that the hospital will burn down.

This statement fits into the defense mechanisms of fantasy. The client encounters thoughts of the hospital burning and her house burns down.

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Correct Answer is D

Explanation

Rationale

A. A. lung biopsy involves obtaining a tissue sample from the lung for microscopic examination. It is typically performed to diagnose conditions such as lung cancer or to investigate unusual findings seen on imaging studies. However, for a client with COPD experiencing increased shortness of breath, a lung biopsy is not typically indicated as a first-line investigation. It is more invasive and usually reserved for specific diagnostic purposes other than routine evaluation of COPD symptoms.

B. Antibody testing is used to detect antibodies specific to certain infections or autoimmune conditions. It is not typically used in the routine evaluation of COPD symptoms unless there is suspicion of a specific autoimmune or infectious cause contributing to exacerbations, which is less common in COPD compared to other conditions.

C. A. sweat test is used to diagnose cystic fibrosis (CF), a genetic disorder that affects the lungs and digestive system. It measures the amount of chloride in sweat, which is elevated in individuals with CF. Since COPD and CF are distinct conditions with different underlying causes and diagnostic criteria, a sweat test is not appropriate for evaluating COPD symptoms.

D. Spirometry is the most appropriate test to schedule for evaluating a client with COPD who reports increased shortness of breath with activity. Spirometry measures lung function by assessing how much and how quickly a person can move air into and out of their lungs. It provides valuable information about the severity of airflow limitation, which is characteristic of COPD.

A. Ear pain and fever. B. Elevated WBC and sedimentation rate. C. Increased BUN and serum creatinine. D. Positive Epstein-Barr, and malaise.

Correct Answer is D

Explanation

Rationale

A. Ear pain is not typically a common symptom of mononucleosis. Fever, however, is commonly seen in mononucleosis due to the body's immune response to the viral infection.

B. In mononucleosis, there is often an increase in white blood cells (specifically lymphocytes) and an elevated sedimentation rate (ESR). These changes reflect the body's immune response to the Epstein- Barr virus infection.

C. Increased blood urea nitrogen (BUN) and serum creatinine levels are not typically associated with mononucleosis. These markers are more indicative of kidney function and are not directly affected by the viral infection causing mononucleosis.

D. A positive test for Epstein-Barr virus (EBV) antibodies is diagnostic for mononucleosis. Malaise, which is a general feeling of discomfort or illness, is a hallmark symptom of mononucleosis along with other systemic symptoms like fatigue, sore throat, swollen lymph nodes, and sometimes a rash.

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Exhibits Click to specify which client statement or behaviors is most likely associated with each of the listed defense mechanisms. Some statements or behaviors may be consistent with more than one mechanism. Each column must have at least one response selected.

Client Statement: A. The client seems unemotional when talking about needing to rebuild her house.

Client Statement: C. The client discusses moving to Hawaii instead of returning to rebuild her house.

Client Statement: B. The client says that she sometimes forgets why she is in the hospital.

Client Statement: D. The client is frightened that the hospital will burn down.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with chronic obstructive pulmonary disease (COPD) reports increased shortness of breath with activity. Which test should the nurse schedule the client for evaluation of the symptoms?

Correct Answer is D

Explanation

The nurse caring for a child with mononucleosis can expect the child to exhibit which symptoms?

Correct Answer is D

Explanation

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?

When preparing a client for an intravenous pyelogram (IVP), it is essential for the nurse to take which action?

A client receives a prescription for heparin 900 units/hr IV. The IV bag contains heparin 25,000 units in 500 mL of 0.45% normal saline. How many mL/hr should the nurse program the infusion pump to deliver? (Enter numerical value only.)

Exhibits The nurse is reviewing the client's chart. For each finding, click to indicate whether findings suggest that the client's condition has improved or put the client at risk for hypovolemia. Each column must have at least one selection.

Exhibits Which other treatment(s) might be helpful for this client? Select all that apply.

A client is admitted to the mental health unit for feelings of depression secondary to a positive HIV report. To provide a safe milieu for this client, which action should the nurse take?

When developing a teaching plan for a client with newly diagnosed type 1 diabetes mellitus, the nurse should explain that an increased thirst is an early sign of diabetic ketoacidosis (DKA). Which action should the nurse instruct the client to implement if this sign of DKA occurs?

Exhibits

Click to specify which client statement or behaviors is most likely associated with each of the listed defense mechanisms. Some statements or behaviors may be consistent with more than one mechanism. Each column must have at least one response selected.