A nurse is caring for a client who states, "My boss accused me of stealing yesterday. I
was so angry I went to the gym and worked out." The nurse should
... [Show More] recognize the client
is demonstrating which of the following defense mechanisms? --CORRECT ANSWER--
Sublimation
Rationale: The client is exhibiting behaviors consistent with sublimation, which is
displayed when a client substitutes socially unacceptable behavior for acceptable
behavior.
A nurse is caring for a client who has generalized anxiety disorder and is to begin taking
alprazolam. Which of the following actions should the nurse take? --CORRECT
ANSWER-- Initiate fall precautions for the client
Rationale: The nurse should initiate fall precautions for a client who has a new
prescription for alprazolam because common adverse effects associated with this
medication are orthostatic hypotension, dizziness, confusion, and lethargy.
A nurse on a med surg unit is caring for a client prior to a surgical procedure. Which of
the following findings should indicate to the nurse that the client has the ability to sign
the informed consent? --CORRECT ANSWER-- The client is able to accurately
describe the upcoming procedure
Rationale: The ability of the client to accurately describe the upcoming procedure
indicates that the provider adequately informed the client and that the client is able to
sign the informed consent
An assistive personnel (AP) and a nurse are turning a client onto the right side. Which
of the following actions by the AP requires the nurse to intervene? --CORRECT
ANSWER-- Places a pillow under the client's right arm.
Rationale: The AP should place a pillow under the client's left arm to prevent internal
rotation of the left shoulder.
A nurse is providing dietary teaching to the parents of a 6-month-old infant. Which of the
following instructions should the nurse include? --CORRECT ANSWER-- Introduce
new foods one at a time over 5 to 7 days.
A nurse is caring for a client who has MRSA in an abdominal wound. Which of the
following precautions should the nurse implement? --CORRECT ANSWER-- Contac [Show Less]