ANSWERS GRADED A+
◉ A patient is being admitted to an inpatient unit for treatment of
anorexia nervosa. Of the following assessment data, which should
the nurse place as highest priority in the plan of care?
A) Weight 24% below normal for height
B) Distorted body image
C) Feelings of inadequacy
D) Frequent vomiting after meals. Answer: D) Frequent vomiting
after meals
◉ All of the following nursing diagnoses are appropriate for the care
of a client with anorexia. Which nursing diagnosis has the highest
priority?
A) Activity intolerance
B) Ineffective coping
C) Chronic low self-esteem
D) Imbalanced nutrition: less than body requirements. Answer: D)
Imbalanced nutrition: less than body requirements
◉ A patient reports a pattern of being suspicious and mistrusting of
others, causing difficulty in sustaining lasting relationships. Which
,stage according to Erikson's psychosocial development was not
successfully completed?
A) Trust
B) Autonomy
C) Initiative
D) Industry. Answer: A) Trust
◉ A client begins to take stock of his life and look into the future.
The nurse assesses that this client is in which of Erikson's
developmental stages?
A) Identity versus role confusion
B) Industry versus inferiority
C) Integrity versus despair
D) Generativity versus stagnation. Answer: C) Integrity versus
despair
◉ A nurse is teaching decision-making skills to a client with
dependent personality disorder. According to Erikson, the likely
cause of the client developing dependent personality is failure to
meet the critical task of which developmental stage?
A) Trust
B) Autonomy
C) Initiative
D) Industry. Answer: D) Industry
,◉ A patient has just been told she has cervical cancer. When asked
about how this is impacting her, she states, "It's just an infection; it
will clear up." The statement indicates that this patient
A) needs education on cervical cancer.
B) is unable to express her true emotions.
C) should be immediately referred to a cancer support group.
D) is using denial to protect herself from an emotionally painful
thought.. Answer: D) is using denial to protect herself from an
emotionally painful thought.
◉ A nursing supervisor reprimands an employee for being
chronically late for work. If the employee handles the reprimand
using the defense mechanism of displacement, he would most likely
do which of the following?
A) Argue with the supervisor that he is usually on time
B) Make a special effort to be on time tomorrow
C) Tell fellow employees that the supervisor is picking on him
D) Tell the unit housekeeper that his work is sloppy. Answer: D) Tell
the unit housekeeper that his work is sloppy
◉ The nurse is assessing a client who is talking about her son's
recent death but who shows no emotion of any kind. The nurse
recognizes this behavior as which of the following defense
mechanisms?
, A) Dissociation
B) Displacement
C) Intellectualization
D) Suppression. Answer: C) Intellectualization
◉ A college student decides to go to a party the night before a major
exam instead of studying. After receiving a low score on the exam,
the student tells a fellow student, "I have to work too much and don't
have time to study. It wouldn't matter anyway because the teacher is
so unreasonable." The defense mechanisms the student is using are
A) denial and displacement
B) rationalization and projection
C) reaction formation and resistance
D) regression and compensation. Answer: B) rationalization and
projection
◉ A client is supposed to be ambulating ad lib. Instead, he refuses to
get out of bed, asks for a bed bath, and makes many demands of the
nurses. He also yells that they are lazy and incompetent. The client's
behavior is an example of which of the following defense
mechanisms?
A) Introjection
B) Projection
C) Rationalization