Patient Data

Exhibits here

The nurse engages the client in conversation about her feelings and some of her coping mechanisms.

Click to specify which client statement or behavior 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 but may have more than one answer selected.

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

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

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

The client is frightened that the hospital will burn down.

Answer and Explanation

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

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

Defense Mechanism: Fantasy

Explanation: The client may be using fantasy as a way to escape from the painful reality of her situation. Discussing moving to a place like Hawaii, which may represent an idealized and stress-free environment, suggests a desire to avoid confronting the challenges and emotions associated with her current circumstances.

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

Defense Mechanism: Isolation

Explanation: Isolation, or emotional isolation, occurs when an individual separates emotions from the events or thoughts associated with them. The client's lack of emotional response when discussing rebuilding her house suggests that she may be isolating her feelings to avoid distress.

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

Defense Mechanism: Suppression

Explanation: Suppression involves the conscious effort to avoid thinking about distressing thoughts or memories. The client's statement that she sometimes forgets why she is in the hospital may indicate an attempt to suppress or avoid focusing on the traumatic event that led to her hospitalization.

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

Defense Mechanism: Denial

Explanation: Denial involves refusing to accept the reality of a situation, which can manifest as irrational fears or beliefs. The client's fear that the hospital will burn down may reflect a form of denial, as she might be projecting her fear of the collapse (a traumatic event) onto another catastrophic event, thereby avoiding dealing with her actual trauma.

Summary of Answers:

A. Fantasy - The client discusses moving to Hawaii instead of returning to rebuild her house.
B. Isolation - The client seems unemotional when talking about needing to rebuild her house.
C. Suppression - The client states that she sometimes forgets why she is in the hospital.
D. Denial - The client is frightened that the hospital will burn down.

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Free Nursing Study Resources

Correct Answer is ["A","B","E"]

Explanation

Choice A rationale:
Measuring blood pressure in both arms can help assess for potential hypertension, which is a common concern in individuals with abdominal obesity and a high waist-hip ratio.

Choice B rationale:
Screening for a family history of diabetes mellitus is important because individuals with abdominal obesity are at increased risk for type 2 diabetes.

Choice C rationale:
Immediate transport to a medical facility is not indicated based solely on the findings of abdominal obesity, high waist-hip ratio, and elevated BMI. These findings may indicate an increased risk for certain health conditions, but they do not necessitate emergency transport.

Choice D rationale:
Restricting fluids and elevating feet is not a standard intervention based solely on the findings described. This action would be more relevant in specific medical situations, such as managing edema.

Choice E rationale:
Discussing the importance of a regular exercise program is appropriate because it can help address obesity and its associated health risks, including diabetes and hypertension.

A. Ask the client why she checks the locks. B. Determine the type and size of the locks. C. Discuss checking the time frequently. D. Plan a list of activities to be carried out daily.

Correct Answer is D

Explanation

A. "Ask the client why she checks the locks."
Asking "why" questions may put the client on the defensive and does not effectively address the compulsive behavior. Clients with obsessive-compulsive disorder (OCD) often do not have a logical explanation for their compulsions.

B. "Determine the type and size of the locks."
This action does not address the client’s compulsive behavior and is not relevant to the nursing intervention. The focus should be on reducing the compulsive behavior rather than assessing the locks themselves.

C. "Discuss checking the time frequently."
This response does not directly address the client’s compulsive checking behavior. Instead, structured interventions that promote time management and coping strategies should be implemented.

D. "Plan a list of activities to be carried out daily."
Providing a structured daily schedule can help redirect the client’s focus away from compulsive behaviors and toward productive activities. A schedule can reduce anxiety and limit the time available for compulsions, promoting better functioning.

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

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

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

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During a routine assessment at an outpatient clinic, the nurse notes that a client has abdominal obesity and a high waist-hip ratio, with a body mass index of 32 kg/m2. Which action(s) should the nurse take in response to these findings? (Select all that apply.)

Correct Answer is ["A","B","E"]

Explanation

A female client engages in repeated checks of door and window locks and behavior that prevents her from arriving on time and interfering with her ability to function effectively. Which action should the nurse take?

Correct Answer is D

Explanation

When the nurse addresses questions to an adult female client who is depressed, the client's responses are delayed. Which intervention should the nurse include in this client's plan of care?

Patient Data Exhibits here The nurse is reviewing the physician's orders. Which of the following physician's orders requires priority attention from the nurse? Select all that apply.

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A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?

A preschool-aged girl tells the school nurse that her hair hurts. The nurse finds that the child's hair has been arranged to cover several small bald spots. Which finding indicates to the nurse that the hair loss is not disease-related?

A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?

The nurse plans to use role-playing as a therapeutic measure. Which individual is most likely to benefit from this type of therapeutic intervention?