Nursing Elites

1. A 10-year-old boy breaks his mother's vase while playing. When the mother asks who broke the vase, the little boy says that his sister did it. The little boy is exhibiting which defense mechanism?

• A. Projection
• B. Displacement
• C. Dissociation
• D. Sublimation

Correct answer: A

Rationale: Projection is a defense mechanism where one attributes their own unacceptable thoughts, feelings, or impulses onto another person. In this scenario, the little boy is projecting his actions onto his sister by falsely claiming she broke the vase. Displacement involves transferring emotions from the original source to a substitute target. Dissociation is a disconnection between thoughts, identity, consciousness, and memory. Sublimation is the redirection of unacceptable impulses into socially acceptable activities.

2. A client with schizophrenia is experiencing delusions. Which of the following interventions should the nurse implement?

• A. Agree with the client's delusions to avoid confrontation.
• B. Challenge the client's delusions directly.
• C. Encourage the client to discuss their delusions in detail.
• D. Present reality and offer reassurance without reinforcing the delusions.

Correct answer: D

Rationale: When caring for a client with schizophrenia experiencing delusions, the nurse should present reality and offer reassurance without reinforcing the client's delusions. This approach helps the client maintain a connection to reality while feeling supported. Agreeing with the delusions may perpetuate false beliefs, while directly challenging them can lead to increased distress for the client. Encouraging the client to discuss their delusions in detail may further exacerbate their symptoms or reinforce their false beliefs. Therefore, the most therapeutic intervention is to gently present reality and provide reassurance to the client.

3. Which of the following is a common side effect of benzodiazepines prescribed for anxiety?

• A. Insomnia
• B. Weight gain
• C. Drowsiness
• D. Increased appetite

Correct answer: C

Rationale: Drowsiness is a common side effect of benzodiazepines prescribed for anxiety. Benzodiazepines work by depressing the central nervous system, which can lead to drowsiness as a side effect. This sedative effect is often desired in the treatment of anxiety disorders, but individuals should be cautious when engaging in activities that require alertness, such as driving, while taking these medications. Insomnia, weight gain, and increased appetite are not typically associated with benzodiazepines; instead, drowsiness and sedation are more common side effects.

4. The mental health team is determining treatment options for a male patient experiencing psychotic symptoms. Which question shouldn't the team answer to determine whether a community outpatient or inpatient setting is most appropriate?

• A. Is the patient expressing suicidal thoughts?
• B. Does the patient have intact judgment and insight into his situation?
• C. Does the patient have experiences with either community or inpatient mental healthcare facilities?
• D. Does the patient require a therapeutic environment to support the management of psychotic symptoms?

Correct answer: C

Rationale: Assessing suicidal thoughts, judgment, insight, and the need for a therapeutic environment are crucial factors in determining the appropriate treatment setting for a patient experiencing psychotic symptoms. Past experiences with mental healthcare facilities do not play a direct role in deciding between a community outpatient or inpatient setting.

5. During an intake assessment, a nurse asks both physiological and psychosocial questions. The client angrily responds, 'I'm here for my heart, not my head problems.' What is the nurse's best response?

• A. It's just a routine part of our assessment. All clients are asked these same questions.
• B. Why are you concerned about these types of questions?
• C. Psychological factors, like excessive stress, have been found to affect medical conditions.
• D. We can skip these questions, if you like. It isn't imperative that we complete this section.

Correct answer: C

Rationale: The nurse should educate the client about the impact of psychological factors, such as excessive stress, on medical conditions. Understanding this connection is crucial in providing holistic care. It is essential to address both physiological and psychosocial aspects during the assessment to obtain a comprehensive understanding of the client's health status and needs. Choice A is incorrect as it doesn't address the importance of psychosocial aspects on medical conditions. Choice B is not the best response as it does not provide valuable information about the connection between psychological factors and medical conditions. Choice D is incorrect because skipping these questions could lead to missing crucial information that may impact the client's overall well-being and treatment plan.

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