Nursing Elites

1. A client who has just been sexually assaulted is calm and quiet. The nurse analyzes this behavior as indicating which defense mechanism?

• A. Denial
• B. Projection
• C. Rationalization
• D. Intellectualization

Correct answer: A

Rationale: The correct answer is A: Denial. In this situation, the client's calm and quiet demeanor after a traumatic event like sexual assault may indicate denial, a defense mechanism where the individual refuses to acknowledge the reality of the distressing event. Choice B, Projection, involves attributing one's thoughts or feelings to others. Choice C, Rationalization, is a defense mechanism where logical reasoning is used to justify behaviors or feelings. Choice D, Intellectualization, is a defense mechanism where excessive reasoning or logic is used to avoid uncomfortable emotions.

2. When a client with schizophrenia is being discharged on antipsychotic medication, what is the most important instruction the nurse should provide?

• A. Stop the medication if you start feeling better.
• B. Be aware of the potential for weight gain with this medication.
• C. Report any unusual muscle movements immediately.
• D. You can drive as soon as you feel ready.

Correct answer: C

Rationale: The correct answer is to instruct the client to report any unusual muscle movements immediately. These movements may indicate extrapyramidal symptoms (EPS) or tardive dyskinesia, which are serious side effects of antipsychotic medications that require immediate attention. Choice A is incorrect because stopping the medication without medical advice can lead to a relapse of symptoms. Choice B is important but not as critical as monitoring for EPS. Choice D is incorrect because driving readiness is not directly related to antipsychotic medication instructions.

3. A client with a diagnosis of schizophrenia is prescribed risperidone (Risperdal). Which statement by the client indicates a need for further teaching?

• A. I can stop taking this medication once I feel better.
• B. I need to avoid foods that are high in tyramine.
• C. I should avoid drinking alcohol while taking this medication.
• D. This medication may cause drowsiness, so avoid driving.

Correct answer: A

Rationale: The correct answer is A. The statement 'I can stop taking this medication once I feel better' indicates a need for further teaching. Antipsychotic medications, like risperidone, should be taken consistently even when symptoms improve to prevent relapse. Choice B is incorrect because avoiding foods high in tyramine is unrelated to risperidone. Choice C is incorrect as avoiding alcohol is a standard precaution with many medications. Choice D is incorrect because being cautious about drowsiness and avoiding driving is a common safety measure associated with risperidone.

4. What is the most therapeutic nursing response for a client with borderline personality disorder who engages in self-mutilating behavior?

• A. Encourage the client to stop hurting themselves.
• B. Discuss what the client was feeling before self-harming.
• C. Inform the client that the behavior will be reported to their doctor.
• D. Ask the client why they hurt themselves.

Correct answer: B

Rationale: The most therapeutic nursing response for a client with borderline personality disorder engaging in self-mutilating behavior is to discuss what the client was feeling before self-harming. This approach helps in exploring the underlying triggers and emotions that lead to self-harm. Option A is directive and may come across as judgmental rather than empathetic. Option C can lead to feelings of betrayal and breach of trust. Option D is a closed-ended question that may not facilitate open communication or exploration of emotions.

5. At a support meeting of parents of a teenager with polysubstance dependency, a parent states, 'Each time my son tries to quit taking drugs, he gets so depressed that I'm afraid he will commit suicide.' The nurse's response should be based on which information?

• A. Addiction is a chronic, incurable disease.
• B. Tolerance to the effects of drugs causes feelings of depression.
• C. Feelings of depression frequently lead to drug abuse and addiction.
• D. Careful monitoring should be provided during withdrawal from the drugs.

Correct answer: C

Rationale: The correct response in this situation should focus on the connection between feelings of depression and drug abuse. Choice A is incorrect because addiction is treatable, not incurable. Choice B is incorrect as tolerance does not directly cause depression. Choice D is not the best response as the parent's concern is about the son's depression leading to suicidal thoughts, not just the withdrawal process.

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