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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

A nurse is performing a dressing change for a hospitalized client with an infected surgical incision. Which actions should the nurse take?

Correct Answer: C

Rationale: Clean gloves for removing soiled dressings prevent contamination, while sterile gloves for applying the new dressing maintain a sterile field. Full PPE is excessive for removal, and clean gloves for application risk infection.

Question 3 of 5

The nurse is caring for a client who has a chest tube connected to a wet suction closed chest drainage system. The nurse should recognize the drainage system is working correctly when gentle, continuous bubbling is present in the

Correct Answer: D

Rationale: Gentle, continuous bubbling in the suction control chamber indicates proper suction in a wet suction system. Bubbling in the water seal suggests an air leak, and the collection chamber does not bubble.

Question 4 of 5

The nurse is reinforcing meal planning teaching to a group of clients with celiac disease. Which meal is appropriate for the nurse to include?

Correct Answer: C

Rationale: Grilled chicken, green beans, and mashed potatoes are gluten-free, suitable for celiac disease. Dinner rolls, breaded pork chops, and spaghetti contain gluten, which must be avoided.

Question 5 of 5

The nurse is contributing to a staff education program about assessing the urinary system. Which statement by a nurse would indicate a correct understanding of the program?

Correct Answer: A

Rationale: An empty bladder is nontender and nonpalpable, indicating correct understanding. Dark brown urine suggests dehydration or other issues, not UTI; kidneys are not always palpable; and percussion is over the costovertebral angle, not lower abdomen.

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