The nurse is caring for a patient who is one day post-mastectomy and notes that she is sobbing and gasping for breath. What should the nurse do first?

Notify the registered nurse.

Raise the head of the bed.

Sit with her and listen to her concerns.

Ask the patient what is wrong.

Answer and Explanation

The Correct Answer is B

Choice A reason: Notifying the registered nurse is important but should come after initially assessing the patient's immediate needs.

Choice B reason: Raising the head of the bed may help with breathing but does not address the cause of the patient's distress.

Choice C reason: Sitting with her and listening to her concerns is supportive but should follow an initial assessment of why she is sobbing and gasping for breath.

Choice D reason: Asking the patient what is wrong is the first step in assessing the situation and providing appropriate care.

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Correct Answer is A

Explanation

Choice A reason: An illusion is a misinterpretation of a real external stimulus. Mr. S is mistaking the cracks in the plaster for snakes, which is an illusion.

Choice B reason: A flashback is a vivid memory of a traumatic event that feels like it is happening again. This does not describe Mr. S's experience.

Choice C reason: A hallucination is a sensory experience of something that does not exist outside the mind. Since Mr. S is misinterpreting an actual visual stimulus (the cracks), it is not a hallucination.

Choice D reason: A delusion is a firmly held false belief resistant to reason or confrontation with actual fact. Mr. S's belief is based on a misinterpretation of a visual stimulus, not a delusion.

A. Regression B. Repression C. Rationalization D. Reaction formation

Correct Answer is C

Explanation

Choice A reason: Regression involves reverting to an earlier stage of development when faced with stress, which is not what Marie is doing.

Choice B reason: Repression involves unconsciously blocking out painful thoughts or feelings, which is different from Marie's conscious rationalization of her failure.

Choice C reason: Rationalization is a defense mechanism where an individual justifies an unacceptable behavior or feeling with a logical reason, avoiding the true explanation for the behavior. Marie is rationalizing her failure by blaming the instructor rather than accepting her own role in the outcome.

Choice D reason: Reaction formation involves behaving in a way that is opposite to what one truly feels, which is not applicable in Marie's case.

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The nurse is caring for a patient who is one day post-mastectomy and notes that she is sobbing and gasping for breath. What should the nurse do first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Mr. S states, "Look at the snakes on the ceiling!" You see some cracks in the plaster. Mr. S is experiencing a/an:

Correct Answer is A

Explanation

Marie has just learned that she has failed her mental health nursing class. She tells her friends, "I knew that instructor was going to fail me. She has never liked me and has just been looking for an excuse to fail me all along." Marie's behavior is an example of which defense mechanism?

Correct Answer is C

Explanation

Which of the following is a priority when caring for a highly anxious patient?

A nurse is caring for a client who has schizophrenia. The client states, "They lie about me all the time and are trying to poison my food." Which of the following responses should the nurse make?

A nurse is reinforcing teaching with a client who is preoperative following abdominal surgery about deep breathing and coughing exercises. Which of the following client statements should indicate to the nurse an understanding of the instructions?

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