A client who was incarcerated for theft is addressing the group in a County Jail health clinic. Which of the following is an example of reaction formation?

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Question 1 of 5

A client who was incarcerated for theft is addressing the group in a County Jail health clinic. Which of the following is an example of reaction formation?

Correct Answer: D

Rationale: The correct answer is D because reaction formation occurs when a person expresses the opposite of what they feel. In this case, the client is advocating for honesty, despite their own history of theft. Choice A discusses stealing to distract from a bad marriage, which does not involve expressing the opposite of one's feelings. Choice B focuses on denial, not reaction formation. Choice C involves delaying emotional discussion, which is not related to expressing the opposite of one's true feelings.

Question 2 of 5

A client is recovering from an acute myocardial infarction. Which of the following interventions should the nurse include in the plan of care?

Correct Answer: D

Rationale: The correct answer is to obtain a cardiac rehabilitation consult. Cardiac rehabilitation is an essential part of the care plan for a client recovering from a myocardial infarction. It helps in improving recovery, enhancing quality of life, and reducing the risk of future cardiac events. Drawing troponin levels and performing EKGs are important for diagnosing and monitoring myocardial infarctions but are not interventions in the post-MI care plan. Oxygen therapy may be necessary based on the client's condition but is not specific to post-MI care.

Question 3 of 5

A nurse is caring for a client who has breast cancer and has been receiving chemotherapy. Which of the following laboratory values should the nurse report to the provider?

Correct Answer: A

Rationale: A WBC count of 3,000/mm3 indicates neutropenia, a dangerous complication of chemotherapy that increases the risk of infection and requires immediate attention. Neutropenia is a common side effect of chemotherapy and can lead to life-threatening infections. Reporting a low WBC count is crucial to ensure timely intervention. Choices B, C, and D are within normal ranges and do not pose immediate risks to the client undergoing chemotherapy.

Question 4 of 5

A home health nurse is carefully planning care for a client with Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?

Correct Answer: A

Rationale: Placing a daily calendar in the kitchen is essential for clients with Alzheimer's disease as it helps in orienting them to time and day, providing structure, and minimizing confusion in their daily routine. This action supports cognitive function and independence. Choice B is incorrect as it does not directly address cognitive orientation. Choice C is not a priority in the care plan and may not significantly impact the client's daily functioning. Choice D, creating variation in the daily routine, can actually increase confusion and anxiety in clients with Alzheimer's disease who thrive on predictability and structure.

Question 5 of 5

During a change-of-shift assessment, a nurse is evaluating four clients. Which finding should the nurse report to the provider first?

Correct Answer: B

Rationale: The nurse should report the client with gastroenteritis who is lethargic and confused to the provider first. Lethargy and confusion in a client with gastroenteritis may indicate dehydration or electrolyte imbalance, both of which can be life-threatening if not addressed promptly. The other options indicate important assessments that require intervention but do not pose an immediate life-threatening risk compared to the client with signs of dehydration and electrolyte imbalance.

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