The nurse is assisting a client, from the bed into a wheelchair, who had a right-side below the knee amputation one day ago. The client states, "I will not be able to do much because of this wheelchair." The client is demonstrating which of the following defense mechanisms?

Displacement

Rationalization

Dissociation

Projection

Answer and Explanation

The Correct Answer is B

A. Displacement: Displacement involves transferring feelings to a less threatening object or person, which is not applicable to the client’s statement.

B. Rationalization: Rationalization involves justifying behaviors or feelings with logical reasons. The client’s statement reflects an unrealistic view rather than justifying actions.

C. Dissociation: Dissociation involves a disconnection from thoughts or feelings, which is not reflected in the client's statement.

D. Projection: Projection involves attributing one’s own feelings or thoughts to others. The client is expressing their own feelings about the wheelchair rather than attributing them to others.

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Correct Answer is A, C, B, D

Explanation

Step 1: A. Inject the amount of air into the modified (cloudy) vial that is equal to the prescribed dose of modified (cloudy) insulin. This step is correct and should be done first. Injecting air into the vial of cloudy insulin (modified) helps to prevent creating a vacuum and makes it easier to withdraw the insulin.

Step 3: B. Invert the vial of non-modified (clear) insulin, then insert the needle into the vial and draw back the prescribed dose. This step should be done after air has been injected into the modified insulin vial. The clear insulin (non-modified) should be drawn first to avoid contamination of the clear insulin with the cloudy insulin.

Step 2: C. Inject the amount of air into the nonmodified (clear) vial that is equal to the prescribed dose of nonmodified (clear) insulin. This step should be done before drawing the insulin from the clear vial. Injecting air into the clear insulin vial helps to equalize the pressure and makes it easier to withdraw the insulin.

Step 4: D. Invert the vial of modified (cloudy) insulin, then insert the needle into the vial and draw back the prescribed dose. This step should be done after drawing the clear insulin. Drawing the cloudy insulin last helps to prevent any contamination of the clear insulin with the cloudy insulin.

A. Assess the patient for physiological indicators of pain. B. Observe the patient for behavior that is indicative of pain. C. Involve the patient in the pain assessment by asking more direct questions. D. Compare the patient's facial expression to a FACES pain scale.

Correct Answer is C

Explanation

A. Assess the patient for physiological indicators of pain. While assessing physiological indicators (such as increased heart rate, blood pressure, or sweating) can provide clues about pain, these signs are not always reliable and can be influenced by other factors. This option does not directly address the patient’s verbal and non-verbal communication about their pain.

B. Observe the patient for behavior that is indicative of pain. Observing the patient’s behavior can be helpful, but it is not sufficient on its own. The patient’s cultural background may influence how they express pain, and relying solely on observation might lead to underestimating their pain.

C. Involve the patient in the pain assessment by asking more direct questions. This is the best option because it respects the patient’s cultural background and encourages a more accurate and detailed assessment of their pain. By asking direct questions, the nurse can gain a better understanding of the patient’s pain experience and provide appropriate care.

D. Compare the patient's facial expression to a FACES pain scale. Using a FACES pain scale can be useful, especially for patients who have difficulty verbalizing their pain. However, this option does not involve the patient in a more detailed discussion about their pain, which is crucial given the cultural context and the patient’s reluctance to openly admit to pain.

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The nurse is assisting a client, from the bed into a wheelchair, who had a right-side below the knee amputation one day ago. The client states, "I will not be able to do much because of this wheelchair." The client is demonstrating which of the following defense mechanisms?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to administer prescribed modified (cloudy) and nonmodified (clear) insulin to a client with type 1 diabetes. Place the following steps in the correct order, that the nurse should take to prepare the medication. All options must be used.

Correct Answer is A, C, B, D

Explanation

Correct Answer is C

Explanation

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