When under stress, a client routinely uses alcohol to excess. When the client's husband finds her drunk, the husband yells at the client about her chronic alcohol abuse. Which action alerts the nurse to the client's use of the defense mechanism of denial?

Correct Answer: D

Rationale: The correct answer is D. The client's statement "I don't drink too much!" demonstrates denial, a defense mechanism where the individual refuses to acknowledge reality. This response indicates the client's inability to accept her excessive alcohol use. A: Hiding liquor bottles in a closet suggests secrecy, not denial. B: Yelling at her son for slouching is displacement, not denial. C: Burning dinner on purpose is passive-aggressive behavior, not denial. In summary, the client's statement denying her alcohol abuse directly reflects the defense mechanism of denial, making it the correct choice in this scenario.

Correct Answer: C

Rationale: The correct answer is C: It obtained permit to operate from DOH. This is because the Records Management and Archives Office of the DOH is responsible for implementing record disposal policies for institutions that are under the jurisdiction of the Department of Health. Obtaining a permit to operate from the DOH indicates that the institution is recognized and regulated by the department, making it subject to the record disposal policies. Choices A, B, and D are incorrect as they do not directly relate to the institution being covered by the record disposal policy of the DOH.

Correct Answer: A

Rationale: The correct answer is A: Localized heat and redness. This is because heat and redness are classic signs of inflammation, which can indicate an infection developing in a surgical incision. The increased blood flow to the area causes heat, and the dilation of blood vessels causes redness. Serosanguinous exudates (choice B) and separation of the incision (choice C) are more indicative of normal wound healing or other complications rather than infection. Blood clots and scar tissue (choice D) are not typical signs of impending infection.

Correct Answer: C

Rationale: The correct answer is C: Take a video of the entire intra-operative procedure. This is not part of JCAHO's universal protocol for surgical and invasive procedures. The other choices are correct as they are essential components of the protocol to prevent wrong site, wrong person, and wrong procedure/surgery. A: Marking the operative site helps ensure the correct site is operated on. B: Conducting pre-procedure verification process ensures all necessary steps are taken before the procedure. D: Conducting a 'time out' immediately before starting the procedure allows the surgical team to confirm key details before proceeding.

Correct Answer: C

Rationale: Rationale: Choice C is correct because eating balanced meals at regular intervals helps regulate colostomy function by maintaining consistent digestion and bowel movements. This ensures proper nutrient absorption and prevents complications. Summary of other choices: A: Irrigating after lunch is unnecessary and can disrupt the natural bowel function. B: While fruits and vegetables are important for overall health, they do not specifically regulate colostomy function. D: Restricting exercise to walking only may not be sufficient for promoting regular bowel movements and overall health.