A nurse is caring for a client who had abdominal surgery 24 hours ago. Which of the following actions is the priority? A. Assess fluid intake every 24 hours B. Ambulate three times a day C. Assist with deep breathing and coughing D. Monitor the incision site for findings of infection✔✔✔ C The priority action the nurse should take when using the airway, breathing, circula- tion approach to client care is to assist the client with deep breathing and coughing, which reduces the risk for postoperative pneumonia.
A nurse is talking with a client who has stage IV breast cancer. The nurse should recognize which of the following statements by the client as a constructive use of a defense mechanism? A. I have experienced physical discomfort when intimate with my partner since my diagnosis B. I wish other women would stop socializing with my partner C. I told my doctor that I would like to start a support group for other 1 / 4 2 / 39 women who are sick in my community D. I used to mistrust my doctor, but now I know that she is the best one to care for me during my illness✔✔✔ C This statement indicates that the client is using the constructive defense mecha- nism sublimation by devising a socially acceptable alternative to facing a reality that she does not wish to accept.
A nurse is caring for a client who has immunosuppression and a continu- ous IV infusion. Which of the following actions should the nurse take? A. Assess the clients IV site every 8 hours B. Check the clients WBC count every 48 hours C. Monitor the clients mouth every 8 hours D. Change the clients IV tubing every 48 hours✔✔✔ C
A nurse is caring for a 2-month-old infant who has Hirschsprung disease (HD). Which of the following areas should the nurse assess for manifesta- tions of HD? A. Eyes area 2 / 4 3 / 39 B. Chest area C. Lower abdominal area✔✔✔ C Hirschsprung disease is a condition that affects the large intestine (colon) and causes problems with passing stool. This is present at birth (congenital) as a result of missing nerve cells in the muscle of the baby’s colon
A nurse at a mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is using dissociation as a defense mechanism? A. A client forgets to buy their partner a birthday gift after a disagreement B. A client who was abused as a child describes the abuse as if it happened to someone else. C. A client who is shorter than average is verbally assertive with coworkers D. A client states that they did not get a job promotion because the boss did not like them✔✔✔ B
A nurse is providing teaching to a client who has a new diagnosis of type 1 diabetes mellitus. The nurse should instruct the client to monitor for which of the following findings as a manifestation of hypoglycemia? A. irritability B. increased urination C. vomiting D. facial flushing✔✔✔ A 3 / 4 4 / 39
A nurse in an outpatient mental health clinic is caring for four clients. The nurse should recognize that which of the following clients is effectively using sublimation as a defense mechanism? A. A client who transfers their anger about their job onto their family and then apologizes B. A client who misses provider appointments because they say they are too busy C. A client who channels their energy into a new hobby following the loss of their job D. A client whose partner died 4 years ago sets a place for him at dinner each night✔✔✔ C The nurse should identify that this client is using the defense mechanism of
