A client is diagnosed with cancer and uses denial to protect the mind from the anxiety of the condition. The client has used which process to deal with the situation?
a. adaptive measures c. defense mechanisms
b. crisis interventions d. maladaptive measures
C
Using defense mechanisms such as denial or rationalization is a universal way in which a person's mind protects itself against anxiety; these mechanisms are not consciously chosen but activate automatically to help maintain psychological homeostasis.
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You are caring for a patient who returned from the tropics 2 weeks ago. The patient has been diagnosed with lymphangitis and is experiencing lymphedema. You are aware that the lymphedema may be due to what?
A) Obstructed lymph vessels B) Sensitivity to antibiotics C) Accumulation of blood D) Improper anticoagulant use
An elderly patient who is being medicated for pain had an episode of incontinence. The nurse realizes that this patient is at risk for developing
1. dehydration. 2. over-hydration. 3. fecal incontinence. 4. a stroke.
A 38-year-old patient with cirrhosis has ascites and 4+ edema of the feet and legs. Which nursing action will be included in the plan of care?
a. Restrict daily dietary protein intake. b. Reposition the patient every 4 hours. c. Place the patient on a pressure-relieving mattress. d. Perform passive range of motion daily.
The nurse has identified deficient knowledge regarding surgery for a client who is scheduled for an outpatient procedure. Which of the following instructional topics will best minimize the cli-ent's anxiety regarding the procedure?
1. Assure the client that preoperative sedation will be administered. 2. Discuss the pre- and postprocedure care that will be provided. 3. Provide a detailed explanation of why the procedure is necessary. 4. Guarantee that family will be regularly updated during the procedure.