A psychiatric nurse intern states, This client's use of defense mechanisms should be eliminated. Which is a correct evaluation of this nurse's statement?

Correct Answer: A

Rationale: Step 1: Defense mechanisms are psychological strategies used unconsciously to cope with anxiety or stress. Step 2: Some defense mechanisms are healthy and adaptive, helping individuals manage difficult emotions. Step 3: Eliminating all defense mechanisms could lead to increased distress and inability to cope effectively. Step 4: Therefore, the correct evaluation is that defense mechanisms can be appropriate responses to stress and need not be eliminated. Summary: Option A is correct because defense mechanisms serve a purpose in managing stress and eliminating them entirely may not be beneficial. Option B is incorrect as not all defense mechanisms are maladaptive.

Correct Answer: D

Rationale: Step-by-step rationale for choosing answer D as the correct option: 1. Respiratory rate assessment is crucial due to the risk of respiratory depression from Fentanyl. 2. Early detection of respiratory depression is vital to prevent adverse outcomes. 3. Monitoring respiratory rate allows timely intervention if abnormalities are detected. 4. This aligns with the nursing priority of ensuring patient safety and well-being. Summary: A: Instructing bed rest is not the priority as mobility is important post-surgery. B: Checking catheter drainage is important but not the priority over respiratory assessment. C: Administering analgesia is important but not as critical as monitoring respiratory rate.

Correct Answer: B

Rationale: The correct answer is B - check for presence of dentures. This is crucial to prevent aspiration of dentures during intubation. Checking for underwear (A) is not directly related to patient safety during anesthesia. Checking patient's ID (C) is important for identification but not a priority pre-anesthesia. Checking baseline vital signs (D) is essential, but not specific to preventing complications related to dentures.

Correct Answer: D

Rationale: The correct answer is D: Practice respiratory isolation. This is the correct answer because respiratory isolation is not a standard health instruction for managing bronchial asthma. The other choices (A, B, C) are all essential instructions for managing asthma. Avoiding emotional stress and extreme temperatures can help prevent asthma attacks. Avoiding pollution like smoking can reduce exposure to irritants that can trigger asthma symptoms. Avoiding allergens like pollens, dust, and seafood can also help prevent asthma exacerbations. In summary, respiratory isolation is not a relevant or effective health instruction for managing bronchial asthma, unlike the other choices which are important for asthma management.

Correct Answer: D

Rationale: Step 1: In the operating room (OR), the two main roles are scrub nurse and circulating nurse. Step 2: Scrub nurse assists the surgeon directly during the procedure. Step 3: Circulating nurse manages the overall OR environment and patient safety. Step 4: Together, they form a complete nursing tandem for every surgery. Step 5: Option D includes both roles, making it the correct answer. Summary: - Option A includes only the instrument technician and circulating nurse, missing the scrub nurse. - Option B includes additional roles like nurse anesthetist and nurse assistant, which are not part of the essential nursing tandem. - Option C includes scrub nurse and nurse anesthetist, missing the circulating nurse role essential for patient safety.