Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse at an urgent care center is caring for a client who sustained minor injuries during a street fight in which two of the client's friends were stabbing victims. The client tells the nurse that he doesn't remember anything that happened after he and his friends first saw the suspects in the stabbing. Which of the following defense mechanisms is the client demonstrating?
A. Projection
Projection is a defense mechanism where an individual attributes their own undesirable thoughts, feelings, or impulses onto someone else.
B. Dissociation
Dissociation is a defense mechanism in which a person disconnects from their thoughts, feelings, memories, or sense of identity as a way to cope with overwhelming or traumatic experiences. In this case, the client's inability to remember anything that happened after seeing the suspects in the stabbing is a form of dissociation. It is a way for the client to psychologically distance themselves from the traumatic event and protect themselves from the emotional distress associated with it.
C. Repression
Repression is a defense mechanism where disturbing or unacceptable thoughts, memories, or feelings are pushed into the unconscious mind.
D. Sublimation
Sublimation is a defense mechanism where unacceptable impulses or emotions are redirected into socially acceptable activities.
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Full Explanation
Dissociation is a defense mechanism in which a person disconnects from their thoughts, feelings, memories, or sense of identity as a way to cope with overwhelming or traumatic experiences. In this case, the client's inability to remember anything that happened after seeing the suspects in the stabbing is a form of dissociation. It is a way for the client to psychologically distance themselves from the traumatic event and protect themselves from the emotional distress associated with it.
A- Projection is a defense mechanism where an individual attributes their own undesirable thoughts, feelings, or impulses onto someone else.
C- Repression is a defense mechanism where disturbing or unacceptable thoughts, memories, or feelings are pushed into the unconscious mind.
D- Sublimation is a defense mechanism where unacceptable impulses or emotions are redirected into socially acceptable activities.
Similar Questions
A nurse is caring for a client following major spinal surgery who is reporting pain. The client's partner tells the nurse, "I wish I could do something to make my wife feel better." Which of the following responses should the nurse make?
A. "It must be very difficult for you to see your wife in pain."
The appropriate response for the nurse in this situation is to acknowledge the partner's concern and empathize with their feelings. By stating, "It must be very difficult for you to see your wife in pain," the nurse acknowledges the partner's emotions and shows understanding and empathy. This response validates the partner's feelings and demonstrates support and compassion.
B. "We're doing everything we can to keep your wife comfortable."
"We're doing everything we can to keep your wife comfortable" may be a true statement, but it does not directly address the partner's expressed wish to do something to help. It may not fully address the emotional aspect of the partner's statement.
C. "I wish there was more that I could do to relieve your wife's pain, too."
"I wish there was more that I could do to relieve your wife's pain, too" is a genuine response that expresses empathy. It acknowledges the partner's desire to help and implies that the nurse shares the same sentiment. This response shows understanding and support.
D. "I'm sure your wife will begin to feel better soon."
"I'm sure your wife will begin to feel better soon" dismisses the partner's concern and does not address their expressed wish to alleviate their wife's pain. It may not fully acknowledge the partner's emotions or provide the support they need in that moment.
Full Explanation
The appropriate response for the nurse in this situation is to acknowledge the partner's concern and empathize with their feelings. By stating, "It must be very difficult for you to see your wife in pain," the nurse acknowledges the partner's emotions and shows understanding and empathy. This response validates the partner's feelings and demonstrates support and compassion.
B- "We're doing everything we can to keep your wife comfortable" may be a true statement, but it does not directly address the partner's expressed wish to do something to help. It may not fully address the emotional aspect of the partner's statement.
C- "I wish there was more that I could do to relieve your wife's pain, too" is a genuine response that expresses empathy. It acknowledges the partner's desire to help and implies that the nurse shares the same sentiment. This response shows understanding and support.
D- "I'm sure your wife will begin to feel better soon" dismisses the partner's concern and does not address their expressed wish to alleviate their wife's pain. It may not fully acknowledge the partner's emotions or provide the support they need in that moment.
A nurse is caring for a client who begins to make sexual advances towards him. Which of the following is an appropriate statement by the nurse?
A. "I'm sure that you don't intend to behave this way, so I'm going to ignore this behavior."
"I'm sure that you don't intend to behave this way, so I'm going to ignore this behavior" is not an appropriate response. Ignoring the behavior can potentially enable or encourage further inappropriate advances, and it does not address the issue directly.
B. "I'm curious as to why you are behaving this way. Can you please explain it to me?"
"I'm curious as to why you are behaving this way. Can you please explain it to me?" places the responsibility on the client to explain their behavior, which is not appropriate or necessary in this situation. It may also encourage further discussion of the inappropriate behavior.
C. "I'm very flattered, but I am married and cannot engage in this behavior."
"I'm very flattered, but I am married and cannot engage in this behavior" personalizes the situation and may give the wrong impression that the nurse's marital status is the reason for rejecting the advances. It is important to maintain professional boundaries and not involve personal factors in the response.
D. "I am going to leave now and I'll return in one hour to spend time with you then."
The appropriate response by the nurse in this situation is to set clear boundaries and remove themselves from the situation. By stating, "I'm going to leave now and I'll return in one hour to spend time with you then," the nurse establishes that the inappropriate behavior is not acceptable and that they will return later to continue providing care within professional boundaries.
Full Explanation
The appropriate response by the nurse in this situation is to set clear boundaries and remove themselves from the situation. By stating, "I'm going to leave now and I'll return in one hour to spend time with you then," the nurse establishes that the inappropriate behavior is not acceptable and that they will return later to continue providing care within professional boundaries.
A- "I'm sure that you don't intend to behave this way, so I'm going to ignore this behavior" is not an appropriate response. Ignoring the behavior can potentially enable or encourage further inappropriate advances, and it does not address the issue directly.
B- "I'm curious as to why you are behaving this way. Can you please explain it to me?" places the responsibility on the client to explain their behavior, which is not appropriate or necessary in this situation. It may also encourage further discussion of the inappropriate behavior.
C- "I'm very flattered, but I am married and cannot engage in this behavior" personalizes the situation and may give the wrong impression that the nurse's marital status is the reason for rejecting the advances. It is important to maintain professional boundaries and not involve personal factors in the response.
A nurse is caring for an older adult client who has dementia and is agitated. The client says, "I have to go home and see my mother." The nurse replies, "You miss your mother." Which of the following therapeutic techniques is the nurse using?
A. Orientation to reality
Orientation to reality involves providing factual information and attempting to reorient individuals with dementia to the present time, place, and situation.
B. Remotivation
Remotivation is a technique used to stimulate memories and engage individuals with dementia in meaningful activities.
C. Validation
Validation is a technique used to acknowledge and validate the emotions and experiences of individuals with dementia, even if their thoughts or perceptions do not align with reality. In this scenario, the nurse responds by saying, "You miss your mother," which shows understanding and empathy toward the client's emotions. The nurse is validating the client's feelings rather than attempting to correct or redirect their thoughts.
D. Guided imagery
Guided imagery involves using vivid language and descriptive prompts to guide individuals into imagining pleasant or calming scenes.
Full Explanation
Validation is a technique used to acknowledge and validate the emotions and experiences of individuals with dementia, even if their thoughts or perceptions do not align with reality. In this scenario, the nurse responds by saying, "You miss your mother," which shows understanding and empathy toward the client's emotions. The nurse is validating the client's feelings rather than attempting to correct or redirect their thoughts.
A. Orientation to reality involves providing factual information and attempting to reorient individuals with dementia to the present time, place, and situation.
B. Remotivation is a technique used to stimulate memories and engage individuals with dementia in meaningful activities.
D. Guided imagery involves using vivid language and descriptive prompts to guide individuals into imagining pleasant or calming scenes.