- (Topic 7)
A 23-year-old female client is brought to the emergency room by her roommate for repeatedly making superficial cuts on her wrists and experiencing wide mood swings. She is very angry and hostile. Her medical diagnosis is adjustment disorder versus borderline personality disorder. The client comments to the nurse, ??Nobody in here seems to really care about the clients. I thought nurses cared about people!?? The client is exhibiting the ego defense mechanism:
Correct Answer:C
(A) Reaction formation is the development and demonstration of attitudes and/or behaviors opposite to what an individual actually feels. The client??s comment does reveal her anger and hostility. (B) Rationalization, another ego defense mechanism, is offering a socially acceptable or seemingly logical explanation to justify one??s feelings, behaviors, or motives. The client??s comment does not reflect rationalization. (C) Splitting, the viewing of people or situations as either all good or all bad, is frequently used by persons experiencing a disruption in self-concept. This ego defense mechanism is reflective of the individual??s inability to integrate the positive and negative aspects of self. (D) Sublimation, the channeling of socially unacceptable impulses and behaviors into more acceptable patterns of behavior, is another ego defense mechanism. The client??s comment reveals that she is not engaging in sublimation.
- (Topic 3)
A pregnant client experiences spontaneous rupture of membranes. The first nursing action is to:
Correct Answer:C
(A) Immediately following membrane rupture, the fetus is at risk for complications, not necessarily the mother. (B) The physician is notified after the nurse completes an assessment of the mother??s and fetus??s conditions. (C) Rupture of membranes facilitates fetal descent. A potential complication is cord prolapse, which is assessed by auscultating fetal heart rate. (D) Rupture of membranes does not necessarily indicate readiness to deliver.
- (Topic 7)
A 30-year-old client has been admitted to the psychiatric service with the diagnosis of schizophrenia. He tells the nurse that when the woman he had been dating broke up with him, the CIA had replaced her with an identical twin. The client is experiencing:
Correct Answer:B
(A) There are no indications that the client??s thoughts reflect special powers or talents characteristic of grandiosity. (B) The client??s thought content is fixed, false, persecutory, and suspicious in nature, which is characteristic of paranoid delusions. (C, D) The client is not demonstrating a sensory experience.