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

Explanation

A. Ask the patient to try to stand up independently to assess the patient's strength first. This action is inappropriate as it may put the patient at risk of falling or injury. The patient should be assisted rather than asked to stand independently.

B. Remind the patient to look up to ensure good positioning when standing up. This is a correct action. Looking up helps the patient maintain better posture and balance when standing.

C. Allow the patient to dangle at the edge of the bed before standing to assess for feelings of dizziness. This is appropriate as it helps to identify any dizziness or orthostatic hypotension before the patient attempts to stand.

D. Assess the patient for any numbness or tingling in the extremities. This is also appropriate as it helps to identify any neurological issues that could affect the patient's ability to stand and transfer safely.

A. Hemiparesis B. Hypertonicity C. Crepitation D. Paraplegia

Correct Answer is D

Explanation

A. Hemiparesis: Hemiparesis refers to weakness on one side of the body, which does not fully describe the inability to move only the legs.

B. Hypertonicity: Hypertonicity refers to increased muscle tone or stiffness, not the inability to move legs.

C. Crepitation: Crepitation refers to a crackling or popping sound in the joints, not the inability to move legs.

D. Paraplegia: Paraplegia refers to the paralysis of the lower half of the body, including the legs, which fits the description of the patient’s condition.

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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 teaching a student nurse how to assist a patient admitted for generalized weakness, to transfer from bed to a chair. The patient has not been out of bed for several days. Which of the following actions by the student nurse requires further teaching?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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