The wife of an alcoholic tells the nurse, "My husband only drinks on the weekends to relax. He has a very stressful job." The nurse recognizes the defense mechanism of:
a. repression.
b. denial.
c. rationalization.
d. identification.
C
Rationalization is a justification for an unreasonable act to make it appear reasonable. Rationali-zation is used by many families to allay their own anxiety about the substance abuse of a family member. Repression refers to unconsciously blocking an unwanted thought or memory from open expression. Denial is ignoring reality in spite of hard evidence. Denial is a mechanism frequently used by substance abusers. Identification refers to modeling behaviors after another individual.
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A patient's arterial blood gas levels indicate a pH of 7.51, PaCO2 of 40 mm Hg, PaO2 of 85 mm Hg, and HCO3 of 32 mEq/L. The patient has been vomiting. The nurse knows the patient has which imbalance?
a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis
The patient comes to the emergency department complaining of coughing and difficulty breathing. The patient's diagnosis is heart failure. He asks the nurse how difficulty breathing could be a heart problem. What is the best response by the nurse?
1. "The right side of your heart has weakened and blood has entered your lungs." 2. "The right side of your heart has enlarged and cannot effectively pump blood." 3. "What you have is called congestive heart failure." 4. "The left side of your heart is weak and pumps blood too quickly." 5. "The left side of your heart has weakened and blood has entered your lungs."
The client is in stage 3 of general anesthesia, known as surgical anesthesia. The nurse anticipates which findings in this client's assessment?
1. Relaxation, stable respiration, and slow eye movements are present. 2. Breathing ceases. 3. Heart rate and breathing become irregular. 4. General sensation is lost.
After being informed that his wife only has a few hours to live, the nurse hears the husband say; "If you take my wife now. I will never pray to you!" What should be the nurse's reply?
a. Call the pastor into the room to speak with the husband. b. Tell the husband to think before saying anything negative. c. Use silence and allow the husband to express his emotions. d. Leave the room and do not be part of this situation.