Nursing Elites

1. A client on the psychiatric unit appears to imitate a certain nurse on the unit. The client seeks out this particular nurse and imitates the nurse's mannerisms. The nurse knows that the client is using which defense mechanism?

• A. Sublimation.
• B. Identification.
• C. Introjection.
• D. Repression.

Correct answer: B

Rationale: The correct answer is (B) Identification. In this scenario, the client is imitating the nurse's mannerisms, which is a form of identification, a defense mechanism where an individual adopts the characteristics or behaviors of someone they admire or view as powerful. (A) Sublimation involves channeling unacceptable impulses into socially acceptable actions, not imitation. (C) Introjection is the internalization of external qualities or attributes, not imitation. (D) Repression is the unconscious exclusion of painful thoughts or memories from awareness, which is not demonstrated in this case.

2. A client with a leg amputation is upset about his appearance. The LPN/LVN intends to address which most closely associated psychosocial problem?

• A. Inability to be mobile
• B. Isolating self from others
• C. Inability to tolerate activity
• D. Concern about body persona

Correct answer: D

Rationale: The correct answer is D. A client with a leg amputation being upset about his appearance is most closely associated with concerns about body image and self-perception. This individual may be worried about how others perceive them, impacting their self-esteem and overall well-being. Choices A, B, and C are incorrect because the primary psychosocial issue in this scenario is related to body image and self-perception, not mobility, social isolation, or activity tolerance.

3. The LPN/LVN is caring for a client with schizophrenia who is experiencing auditory hallucinations. Which intervention is most appropriate?

• A. Encourage the client to focus on reality-based activities.
• B. Ask the client to describe the voices he hears.
• C. Tell the client that the voices are not real.
• D. Encourage the client to interact with others who are not experiencing hallucinations.

Correct answer: B

Rationale: Asking the client to describe the voices he hears is the most appropriate intervention in this situation. It helps the nurse assess the content and severity of the hallucinations, enabling the planning of appropriate interventions. Choice A is not as effective as directly addressing the hallucinations. Choice C may lead to mistrust as the client believes the voices are real. Choice D does not address the client's immediate need related to the hallucinations.

4. A nurse determines that the wife of an alcoholic client is benefitting from attending an Al-Anon group when the nurse hears the wife say:

• A. I no longer feel that I deserve the meetings my husband inflicts on me.
• B. My attendance at the meetings has helped me to see that I provoke my husband's violence.
• C. I enjoy attending the meetings because they get me out of the house and away from my husband.
• D. I can tolerate my husband's destructive behaviors now that I know they are common with alcoholics.

Correct answer: A

Rationale: Choice A is the correct answer as the statement indicates the wife understands that her husband's behavior is not her fault and is benefitting from the group support. Choice B is incorrect as it suggests self-blame rather than recognizing the husband's responsibility. Choice C is incorrect as the benefit is related to emotional support and understanding, not just getting away from the husband. Choice D is incorrect as tolerating destructive behaviors is not a healthy outcome of attending support groups.

5. A client with depression reports difficulty sleeping. What is the most appropriate nursing intervention?

• A. Encourage the client to take short naps during the day.
• B. Suggest the client drink a warm beverage before bedtime.
• C. Recommend the client exercise immediately before bedtime.
• D. Advise the client to take a sleep aid nightly.

Correct answer: B

Rationale: The most appropriate nursing intervention for a client with depression reporting difficulty sleeping is to suggest the client drink a warm beverage before bedtime. A warm beverage can promote relaxation and help establish a bedtime routine, which may aid in improving sleep quality. Encouraging short naps during the day (Choice A) may disrupt the client's nighttime sleep pattern. Recommending exercise immediately before bedtime (Choice C) can have a stimulating effect, making it harder for the client to fall asleep. Advising the client to take a sleep aid nightly (Choice D) should only be considered after other non-pharmacological interventions have been attempted and in consultation with a healthcare provider due to potential side effects and risks associated with sleep aids.

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