Correct Answer: D

Rationale: The adult client is displaying regression a defense mechanism where an individual reverts to an earlier stage of development in response to stress or conflict. Throwing a temper tantrum a behavior typical of young children indicates regression to a less mature coping mechanism when the client does not get his way. Repression (
A) involves suppressing memories rationalization (
B) justifies behavior and reaction formation (
C) involves acting opposite to true feelings none of which fit the scenario.

Correct Answer: C

Rationale: The nurse should witness the client’s signature on the consent form to ensure informed consent verifying that the client is signing voluntarily and understands the procedure risks benefits and alternatives. This is the nurse’s primary role in the informed consent process. Explaining the procedure (
A) and risks and benefits (
D) are the physician’s responsibilities and obtaining consent (
B) is not within the nurse’s scope.

Correct Answer: C

Rationale: Values clarification is the process of assisting another to clarify their own values in order to facilitate decision-making. In this case the client who has been blinded as a result of an injury has informed the nurse of her plans to return to her counseling practice and work full-time. This demonstrates that the client has prioritized her values and made a decision based on them reflecting the prioritizing aspect of values clarification where the client evaluates and ranks her values to guide her actions.

Correct Answer: B

Rationale: Anxiety is an appropriate nursing diagnosis for a client experiencing hypoxia as hypoxia can cause shortness of breath and difficulty breathing leading to feelings of anxiety. Hypothermia nausea and pain are not directly related to hypoxia which primarily affects oxygenation and can trigger psychological responses like anxiety.

Correct Answer: C

Rationale: The nurse’s role in the informed consent process is to witness the client’s signature on the consent form verifying that the client is signing voluntarily and has been informed about the procedure. Explaining the procedure (
A) and risks and benefits (
D) is the responsibility of the physician performing the procedure and obtaining consent (
B) is also the physician’s role. The nurse may clarify information if the client has questions but witnessing the signature is the primary action.