A 16-year-old patient is brought into the emergency department (ED) after being attacked in an alley. The patient states that she "can't see," but that she is otherwise "okay." The initial assessment reveals no physiological reason for
but several bruises, cuts, and abrasions are noted. After a thorough assessment, the patient is diagnosed with posttraumatic stress disorder (PTSD). The nurse knows that the patient is employing which defense mechanisms? Select all that apply.
1. Denial
2. Projection
3. Conversion
4. Suppression
5. Displacement
Answer: 1, 3, 4
Explanation: The patient is using conversion, denial, and suppression as defense mechanisms. Conversion transfers mental conflict or trauma into a physical symptom. Denial is avoiding, ignoring, or rejecting a situation and the feelings associated with it. Suppression is the conscious denial of a disturbing situation or feeling. Displacement transfers emotions from one person, or object to another less threatening or more neutral person or object. Projection attributes thoughts or impulses to another person.
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a. Battery-operated DVD player b. Book c. Potted plant d. Box of candy
When caring for a postpartum woman experiencing hypovolemic shock, the nurse recognizes that the most objective and least invasive assessment of adequate organ perfusion and oxygenation is
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The nurse is developing a long-range care plan for a client diagnosed with a hereditary hearing disorder that is progressive. The nurse should include which of the following in the plan?
1. Communication instruction 2. Learning to avoid same exposure that caused the disorder 3. Delaying use of assistive devices 4. Minimize effects of hearing disorder
An elderly client tells the nurse that he has been having increasing difficulty walking and he has reduced range of motion in both hips. The nurse suspects that which of the following is occurring with this client?
1. Loss of elasticity of the ligaments and tendons 2. Reduction in blood supply to the hips 3. Interruption in nerve supply to the hips 4. Hairline fractures of both hips