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Questions 164

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Question 1 of 5

The nurse in the mental health unit observes a client hitting the wall repeatedly with the hands after an upsetting family therapy session. The nurse should recognize that the client is exhibiting which of the following defense mechanisms?

Correct Answer: B

Rationale: Defense mechanisms are unconscious mental processes used to protect individuals from uncomfortable thoughts, internal conflicts, and external stresses. Defense mechanisms may be therapeutic to clients with anxiety. However, with excessive use, defense mechanisms may become notherapeutic because they involve a degree of self-deception and reality distortion that can result in poor interpersonal relationships, irrational behavior, and decreased productivity.

Question 2 of 5

The nurse in the mental health unit is observing staff members communicating with assigned clients. Which of the following statements by a staff member to a client would require the nurse to intervene?

Correct Answer: D

Rationale: Asking 'why' can seem judgmental and provoke defensiveness, hindering therapeutic communication. Seeking clarification, acknowledging beliefs, and inviting elaboration are appropriate and supportive.

Question 3 of 5

The women’s health nurse is caring for a 30-year-old client who wants to use the ethinyl estradiol and norelgestromin patch for contraception. Regarding this method of birth control, which finding should be most concerning to the nurse?

Correct Answer: C

Rationale: Deep venous thrombosis is a contraindication for estrogen-containing contraceptives like the patch due to increased clotting risk. Heavy menses, family history of breast cancer, and obesity are less critical.

Question 4 of 5

The nurse monitors a child who has been treated for an acute asthma exacerbation. Which finding is the best indicator that treatment has been effective?

Correct Answer: B

Rationale: Absence of wheezes indicates open airways, the primary goal of asthma treatment. Reduced coughing and improved oxygen saturation are positive but less specific than clear lungs.

Question 5 of 5

An adult is admitted for surgery today. Immediately after administering the preoperative medications of meperidine and atropine, the nurse notes that the operative permit has not been signed. Which action should the nurse take?

Correct Answer: D

Rationale: Preoperative medications like meperidine impair judgment, making consent invalid post-administration. Reporting to the physician to delay surgery ensures legal and ethical consent.

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