A nurse is caring for a client who smokes and has lung cancer. The client reports, I'm coughing because I have that cold that everyone has been getting." The nurse should identify that the client is using which of the following defense mechanisms?
a. Reaction formation
b. Denial
c. Displacement
d. Sublimation
What is b? Denial
Mike, a 43-year old construction worker, has a history of hypertension. He smokes two packs of cigarettes a day, is nervous about the possibility of being unemployed, and has difficulty coping with stress. His current concern is calf pain during minimal exercise that decreased with rest. The nurse assesses Mike’s symptoms as being associated with peripheral arterial occlusive disease. The nursing diagnosis is:
a. Alteration in tissue perfusion related to compromised circulation
b. Dysfunctional use of extremities related to muscle spasms
c. Impaired mobility related to stress associated with pain
d. Impairment in muscle use associated with pain on exertion
What is a. Alteration in tissue perfusion related to compromised circulation
When caring for a patient who has started anticoagulant therapy with warfarin (Coumadin), the nurse knows not to expect therapeutic benefits for:
a. At least 12 hours
b. The first 24 hours
c. 2-3 days
d. 1 week
What is c. 2-3 days
A nurse in an acute mental health facility is caring for a client who has bipolar disorder. Which of the following is the priority nursing action?
a. Set consistent limits for expected client behavior
b. Administer prescribed medications as scheduled
c. Provide the client with step-by-step instructions during hygiene activities
d. Monitor the client for escalating behavior
What is d. Monitoring for escalating behaviors addresses the client's priority need for safety and is therefore the priority action.
A nurse is providing discharge information to a patient with peripheral vascular disease. Which of the following information should be included in instructions?
a. Walk barefoot whenever possible.
b. Use a heating pad to keep feet warm.
c. Avoid crossing the legs.
d. Use antibacterial ointment to treat skin lesions at risk of infection.
What is c. avoid crossing legs