A client becomes upset when the physician diagnoses diabetes mellitus as the cause of current signs and symptoms. The client tells the nurse, "This must be a mistake. No one in my family has ever had diabetes." Based on this statement, the nurse suspects the client is using which coping mechanism?

Correct Answer: A

Rationale: The client's response of stating that diabetes cannot be possible because it is not prevalent in the family indicates that the client is using the coping mechanism of denial. Denial is a common defense mechanism where individuals refuse to accept reality or facts that are too uncomfortable for them to acknowledge. In this situation, the client is denying the diagnosis of diabetes as a way to cope with the distressing news, hoping that it may not be true because it has not affected their family members in the past. Recognizing this coping mechanism is important for the nurse to provide support and education to help the client come to terms with the diagnosis and start managing the condition effectively.

Correct Answer: C

Rationale: When using crutches after an above the knee amputation, it is important for the client to support their weight primarily on their elbows. Placing the weight on the elbows helps to prevent pressure on the axilla (armpit area), which can lead to nerve damage and discomfort. Supporting weight on the elbows also provides better stability and control while using crutches, allowing the client to move more safely and comfortably. Additionally, distributing the weight onto the elbows helps to avoid potential strain and injury to the hands or upper arms.

Correct Answer: A

Rationale: In this situation where Mr. Mariano has an open fracture of the left humerus, the nurse's critical assessment finding should be the status of the client's tetanus immunization. An open fracture poses a risk of infection, and tetanus is a concern due to the potential exposure to bacteria from the environment causing tetanus. Tetanus is a serious bacterial infection that affects the nervous system and can be fatal if not treated promptly. Knowing the client's tetanus immunization status will help determine the need for a tetanus booster to prevent this potentially life-threatening infection. Blood alcohol level, support systems at home, and voiding time are important assessments as well, but in the case of an open fracture, the priority is to assess the risk of tetanus infection.

Correct Answer: A

Rationale: The circulating nurse is responsible for ensuring the cleanliness, proper temperature, humidity, and lighting in the operating room. The circulating nurse plays a crucial role in maintaining the overall environment and ensuring that it meets the necessary standards for the safety and well-being of the patient and the surgical team. They are in charge of coordinating and overseeing all aspects of the operating room environment, including maintaining a sterile field, assisting with instrument setup, and ensuring that all equipment is functioning properly. Additionally, the circulating nurse manages communication within the operating room and ensures that all necessary supplies are available during the surgical procedure. It is within the circulating nurse's scope of practice to take charge of these responsibilities to create an optimal operating room environment.

Correct Answer: D

Rationale: A patient experiencing an exacerbation of COPD, especially due to an infection, requires a diet that is high in calories and protein. This is because during exacerbations, the body's energy requirements increase due to increased work of breathing and inflammation. High-calorie intake helps provide the necessary energy for breathing and healing. Additionally, a high-protein diet is important for maintaining respiratory and skeletal muscle strength, which can be affected during exacerbations of COPD. Therefore, a high-calorie high-protein diet would be most appropriate for Aling Maria to support her recovery and overall health during this period.