After throwing his lunch tray on the floor, the patient complains to the nurse manager about the quality of the food he is being fed during his hospital stay. In this following scenario, what defense mechanism is this patient using?

Correct Answer: C

Rationale: The correct answer is C: Rationalization. The patient is justifying or making excuses for his behavior of throwing the lunch tray by complaining about the quality of the food. This defense mechanism allows him to avoid taking responsibility for his actions by attributing them to external factors. Denial (A) would involve refusing to acknowledge his behavior, displacement (B) would be redirecting his emotions to a different target, and repression (D) would involve unconsciously blocking out the memory of his behavior. In this scenario, rationalization best fits as the patient is attempting to make his actions seem reasonable or justified.

Correct Answer: B

Rationale: The correct answer is B: Call the HCP to discuss the order. This is the best course of action because it allows the nurse to clarify the order directly with the healthcare provider. By communicating with the HCP, the nurse can ensure patient safety by confirming the correct dosage and potentially prevent medication errors. Informing the nursing supervisor (Choice A) may be necessary but should not be the first step. Giving the drug as ordered (Choice C) poses a risk if the dose is indeed too high. Giving the standard dose (Choice D) without clarification may not align with the HCP's intention. Communication with the HCP is essential for patient safety and adherence to proper protocols.

Correct Answer: A

Rationale: The correct answer is A: Cardiac. When a client presents with chest pain, the nurse should address the cardiac area first because it is essential to rule out potentially life-threatening conditions like a heart attack. The heart is a vital organ, and any issues related to it require immediate attention. Respiratory issues could also cause chest pain, but cardiac concerns must be prioritized due to their severity. Gastrointestinal and musculoskeletal causes of chest pain are typically less urgent and can be considered after cardiac concerns have been addressed.

Correct Answer: B

Rationale: The correct answer is B: health literacy. Health literacy refers to the ability of an individual to understand and use health information to make informed decisions about their health. Basic literacy (A) is general reading and writing skills. Medical literacy (C) is specifically understanding medical information. Consumer literacy (D) is about understanding consumer rights and responsibilities. Health literacy is unique as it focuses on health-related information specifically.

Correct Answer: C

Rationale: The correct answer is C: sensory deprivation. Sensory deprivation refers to the lack of meaningful stimuli to the senses, which can occur in a blind individual. In the ICU, the client's visual impairment, coupled with the need for contact precautions, restricts sensory input, leading to sensory deprivation. This can result in feelings of isolation, anxiety, and confusion. Choice A, sensory deficit, refers to a general impairment in any of the senses, not necessarily related to the client's specific situation. Choice B, sensory overload, involves an excessive amount of sensory stimuli, which is unlikely in a visually impaired client. Choice D, sensory overstimulation, implies an overwhelming amount of sensory input, which is not the case for a blind client in the ICU.