A client receiving preoperative instructions asks questions repeatedly about when to stop eating the night before the procedure. The nurse tries to refocus the client. The nurse notes that the client is frequently startled by noises in the hall. Assessment reveals rapid speech, trembling hands, tachypnea, tachycardia, and elevated blood pressure. The client admits to feeling nervous and having trouble sleeping.Based on the assessment, the nurse documents that the client has ______________.
Answer(s): C
In severe anxiety, a client focuses on small or scattered details. The person is unable to solve problems. With mild anxiety, stimuli are readily perceived and processed, and the ability to learn and solve problems is enhanced.Moderate anxiety narrows the perceptual field, but the client notices things brought to his attention. During a panic attack, the person is disorganized and might be hyperactive or unable to speak or act.
The highest incident of child abuse occurs in children in which age group?
Answer(s): A
Children between birth and 3 years of age have the highest rates of victimization (at 16 per 1,000 children). Girls are slightly more likely to be victims than boys.
An adult who had been abused as a child is discussing the group therapy program. Which statement indicates that the client has gained insight?
Answer(s): B
Children who are abused learn to cope with the painful experiences by ignoring painful feelings and avoiding getting close to people.As adults, victims of abuse usually continue to repress feelings, avoid close interpersonal relationships, and frequently use alcohol or drugs to block painful memories.Long-term effects in adults might include criminal/violent behavior (for adult males), substance abuse, and a variety of social and emotional problems (including suicidal thoughts, anxiety, hostility, dissociation, and interpersonal difficulties).
Two staff nurses were considered for promotion to head nurse. The promotion is announced via a memo on the unit bulletin board. The nurse who was not promoted tells a friend, “Oh, well, I really didn’t want the job anyway.”This is an example of ______________.
This is called the sour grapes form of rationalization. Rationalization is an unconscious form of self-deception in which excuses are made.Denial is an unconscious process that ignores the existence of the situation. Projection operates unconsciously and results in blaming behavior.Compensation is an attempt to make up for a perceived weakness by emphasizing a strong point.
The nurse who was not promoted tells another friend, “I knew I’d never get the job. The hospital administrator hates me.”If she actually believes this of the administrator, who, in reality, knows little of her, she is demonstrating ______________.
Projection results in unconsciously adopting blaming behavior. It attributes unacceptable attributes to other people.Compensation results in the nurse unconsciously attempting to emphasize a strong point in an attempt to make up for a perceived weakness.Reaction formation unconsciously adopts behavior that is opposite her actual feelings. Denial involves ignoring the existence of an unpleasant reality.
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