a patient who is displaying the defense mechanism of compensation would

NCLEX-RN

NCLEX RN Actual Exam Test Bank

1. A patient who is displaying the defense mechanism of Compensation would:

A. Refuse to hear unwanted information.
B. Transfer feelings of negativity to someone else.
C. Overemphasize behaviors which accommodate for perceived weaknesses.
D. Place blame on others for personal actions or mistakes.

Correct answer: C

Rationale: The correct answer is 'Overemphasize behaviors which accommodate for perceived weaknesses.' Compensation involves overemphasizing or exaggerating a particular behavior or trait to make up for or cover up perceived weaknesses in oneself. This defense mechanism allows individuals to focus on their strengths rather than acknowledging their shortcomings. Choices A, B, and D are incorrect. Refusing to hear unwanted information relates more to denial, transferring feelings of negativity to someone else is projection, and placing blame on others is an example of the defense mechanism known as externalization.

2. What is the first aid for frostbite?

A. Running cold water over the affected area. Warm or hot water will shock the area and cause more tissue damage.
B. Run warm water over the area to rapidly rewarm the affected area.
C. Run hot water over the area to warm the area as quickly as possible.
D. Cover the area with a blanket, using a heating pad if the blanket isn't warm enough.

Correct answer: A

Rationale: First aid for frostbite involves running cold water over the affected area. It is important to avoid warm or hot water as it can shock the area and cause further tissue damage. Warm water should not be used to rapidly rewarm the affected area. Similarly, hot water should also be avoided as it can warm the area too quickly and potentially cause harm. Covering the area with a blanket and using a heating pad may not be effective and can even lead to more damage. Seeking medical assistance is crucial if the tissue appears necrotic to prevent further complications.

3. A patient is diagnosed with essential hypertension. Which of the following blood pressures would you expect to see in this patient prior to taking medications for the condition?

A. 142/92
B. 118/72
C. 120/80
D. 138/88

Correct answer: A

Rationale: Before starting medications for essential hypertension, a patient would typically present with a blood pressure reading equal to or greater than 140/90. This indicates high blood pressure and is characteristic of essential hypertension. Choice A, 142/92, falls within this range, making it the correct answer. Choices B (118/72), C (120/80), and D (138/88) all have blood pressure readings that are within the normal range and would not typically be expected in a patient diagnosed with essential hypertension. Therefore, choices B, C, and D are incorrect as they do not align with the elevated blood pressure levels seen in essential hypertension.

4. A patient is seen in the clinic for reports of "fainting episodes that started last week."? How would the nurse proceed with the examination?

A. Blood pressure readings are taken in both arms and thighs.
B. The patient is assisted to a lying position, and their blood pressure is taken.
C. The patient's blood pressure is recorded in lying, sitting, and standing positions.
D. The patient's blood pressure is recorded in lying and sitting positions; these numbers are then averaged to obtain a mean blood pressure.

Correct answer: C

Rationale: When a patient reports fainting episodes, it is crucial to assess for orthostatic hypotension. If the nurse suspects volume depletion, the patient has hypertension, is on antihypertensive medications, or has a history of fainting or syncope, blood pressure readings should be taken in three positions: lying, sitting, and standing. This assessment helps detect orthostatic hypotension, which can provide valuable information about the patient's condition. Taking blood pressure readings in multiple positions allows for a comprehensive evaluation of possible postural changes in blood pressure. Choices A, B, and D are incorrect because they do not cover the necessary positions to assess for orthostatic hypotension effectively.

5. A patient is asked to abduct her arms. Which of the following accurately describes her arm movement?

A. She moves her arms away from her trunk
B. She moves her arms toward her trunk
C. She rotates her arms at the wrists while holding them away from her body
D. She crosses her arms over her abdomen

Correct answer: A

Rationale: Abduction refers to moving a body part away from the midline of the body. In this case, when the patient abducts her arms, she is moving them away from her trunk. Choice A is correct. Choices B, C, and D are incorrect. Choice B describes adduction, which is the movement of a body part toward the midline. Choice C describes wrist rotation, not arm abduction. Choice D describes crossing the arms over the abdomen, which is not the movement associated with abduction.