You forgot to assist a resident with ambulation. You tell the nurse that you have too much work to do. Which defense mechanism are you using?
a. Projection
b. Identification
c. Rationalization
d. Substitution
C
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The nurse discovers that the client suddenly has become short of breath. Which of the following assessment findings would increase the nurse's suspicion of a spontaneous pneumothorax of the left lung? Standard Text: Select all that apply
1. Diminished breath sounds in the bases bilaterally, with rhonchi in the left lower lobe 2. Trachea is at midline. 3. Subcutaneous emphysema palpable on the left side of the chest 4. Absent breath sounds on the left side of the chest 5. Tachycardia and tachypnea
Depression in the elderly is
1. rare. 2. common. 3. nonexistent. 4. seen occasionally.
A patient tells the nurse that since taking a medication he has suffered from excessively dry mouth. Which of the following assessments would be needed to plan interventions for that symptom?
a. Asking the patient whether foods taste different now b. Checking the patient's sense of smell c. Having the patient stand to check for balance d. Assessing for a history of seizures
A patient who will require long-term mechanical ventilation has had a tracheostomy for 2 weeks. The nurse is concerned that stoma erosion is occurring. Which nursing assessment would support the nurse's concern?
1. Secretions are present at the stoma opening. 2. Granulation tissue is noted at the stoma site. 3. The patient has developed a dry cough. 4. The skin at the stoma opening is flaky.