Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse in an urgent care facility is caring for a client who has traumatic injuries following an assault. The client sits quietly and calmly tells the nurse, "I'm fine." The nurse should recognize the client's behavior as which of the following reactions?
A. Projection
Projection would involve the client attributing their own feelings to others.
B. Displacement
Displacement, would involve the client redirecting their emotions onto someone or something else.
C. Denial
The client's behavior of stating "I'm fine" despite having traumatic injuries is an example of denial, a coping mechanism that involves denying that a problem or issue exists. Projection involves attributing one's own feelings to another person, displacement involves redirecting one's emotions onto a less threatening target, and undoing involves seeking to undo or forget past actions.
D. Undoing
Undoing, would involve the client attempting to forget or undo past actions.
This question is an excerpt from Nurse Dive's nursing test bank - PNU Adult Health II Spring 2023 Proctored Exam 2. Take the full exam now
Full Explanation
The client's behavior of stating "I'm fine" despite having traumatic injuries is an example of denial, a coping mechanism that involves denying that a problem or issue exists. Projection involves attributing one's own feelings to another person, displacement involves redirecting one's emotions onto a less threatening target, and undoing involves seeking to undo or forget past actions.
Choice A, projection, would involve the client attributing their own feelings to others.
Choice B, displacement, would involve the client redirecting their emotions onto someone or something else. Finally,
choice D, undoing, would involve the client attempting to forget or undo past actions.
Similar Questions
A nurse facilitating a group therapy session is listening to clients discuss their coping strategies when feeling stressed. Which of the following statements indicates adaptive coping? (Select all that apply.)
A. "I sleep in in the mornings."
"I sleep in in the mornings," is not an adaptive coping strategy because it doesn't address the source of stress and may actually lead to avoidance.
B. "I isolate myself in my room for a few hours when things get overwhelming."
"I isolate myself in my room for a few hours when things get overwhelming," is not adaptive because it promotes social withdrawal and avoidance.
C. "I call a friend who makes me smile and laugh."
This is anadaptive coping strategy that helps to reduce stress and promote relaxation. Calling a friend who makes you smile and laugh, for example, can help to distract from negative thoughts and promote positive emotions.
D. "I think about being on my favorite beach vacation."
"I think about being on my favorite beach vacation," is not adaptive because it promotes avoidance and doesn't address the source of stress.
E. "I tense and release my muscles, starting with my feet."
This is an adaptive coping strategy that helps to reduce stress and promote relaxation. Tense and release exercises can help to reduce muscle tension and promote relaxation.
Full Explanation
"I call a friend who makes me smile and laugh," and "I tense and release my muscles, starting with my feet." These are adaptive coping strategies that help to reduce stress and promote relaxation. Calling a friend who makes you smile and laugh, for example, can help to distract from negative thoughts and promote positive emotions. Tense and release exercises can help to reduce muscle tension and promote relaxation.
Choice A, "I sleep in in the mornings," is not an adaptive coping strategy because it doesn't address the source of stress and may actually lead to avoidance.
Choice B, "I isolate myself in my room for a few hours when things get overwhelming," is not adaptive because it promotes social withdrawal and avoidance.
Choice D, "I think about being on my favorite beach vacation," is not adaptive because it promotes avoidance and doesn't address the source of stress.
A nurse is helping a client relieve stress through cognitive reframing. Which of the following actions by the client demonstrates effective use of cognitive reframing?
A. The client imagines being in a quiet, relaxing environment.
"The client imagines being in a quiet, relaxing environment," is not an example of cognitive reframing, but rather an example of visualization, which can also be useful in reducing stress.
B. The client trains his mind to relax by using deep inner resources.
"The client trains his mind to relax by using deep inner resources," is not an example of cognitive reframing, but rather an example of relaxation training.
C. The client learns to change negative thoughts into positive statements.
"The client learns to change negative thoughts into positive statements." This demonstrates the effective use of cognitive reframing, which involves changing negative thoughts into positive self-talk. This strategy can help to reduce stress and improve coping skills.
D. The client learns the source of his stress by writing down daily events.
"The client learns the source of his stress by writing down daily events," is not an example of cognitive reframing, but rather an example of stress management through self-reflection.
Full Explanation
"The client learns to change negative thoughts into positive statements." This demonstrates the effective use of cognitive reframing, which involves changing negative thoughts into positive self-talk. This strategy can help to reduce stress and improve coping skills.
Choice A, "The client imagines being in a quiet, relaxing environment," is not an example of cognitive reframing, but rather an example of visualization, which can also be useful in reducing stress.
Choice B, "The client trains his mind to relax by using deep inner resources," is not an example of cognitive reframing, but rather an example of relaxation training.
Choice D, "The client learns the source of his stress by writing down daily events," is not an example of cognitive reframing, but rather an example of stress management through self-reflection.
A nurse on an inpatient unit is caring for a newly-admitted client who has anorexia nervosa. Which of the following actions should the nurse take? (Select all that apply.)
A. Stay with the client during meals and for 1 hr afterward.
"Stay with the client during meals and for 1 hr afterward," This is an important intervention for clients with anorexia nervosa, as they can help to prevent complications such as dehydration and electrolyte imbalances.
B. Give the client a weight gain goal of 4 to 5 lb per week.
"Give the client a weight gain goal of 4 to 5 lb per week," is not an appropriate intervention, as it can be overwhelming and may promote unhealthy weight gain.
C. Monitor the client's weight daily after first voiding.
"Monitor the client's weight daily after first voiding." This is animportant intervention for clients with anorexia nervosa, as it can help to prevent complications such as dehydration and electrolyte imbalances.
D. Encourage the client to keep a diary of daily food intake.
Encourage the client to keep a diary of daily food intake: Keeping a food diary is an effective way to help clients with anorexia nervosa become more aware of their eating patterns and nutritional intake. It can provide useful insights for both the client and the healthcare team and can be part of therapy to address distorted thinking around food.
E. Offer specific privileges for sustained weight gain.
Offer specific privileges for sustained weight gain: Offering privileges for weight gain can be part of a structured approach to motivate the client. Rewards or privileges for meeting weight gain milestones can be an incentive, though this should be done cautiously and in conjunction with other therapeutic approaches. It is important to avoid using food-related privileges that could reinforce disordered eating behaviors.
Full Explanation
"Stay with the client during meals and for 1 hr afterward," and "Monitor the client's weight daily after first voiding." These are important interventions for clients with anorexia nervosa, as they can help to prevent complications such as dehydration and electrolyte imbalances.
Choice B, "Give the client a weight gain goal of 4 to 5 lb per week," is not an appropriate intervention, as it can be overwhelming and may promote unhealthy weight gain.
Choice D, "Encourage the client to keep a diary of daily food intake," may be helpful for some clients, but is not a priority intervention.
Choice E, "Offer specific privileges for sustained weight gain," is not an appropriate intervention.