Nursing Elites

1. A client is experiencing alcohol withdrawal. Which symptom should the nurse identify as a priority to address?

• A. Tremors
• B. Nausea and vomiting
• C. Increased blood pressure
• D. Insomnia

Correct answer: C

Rationale: During alcohol withdrawal, increased blood pressure is a critical symptom that requires immediate attention. Elevated blood pressure can lead to serious complications such as cardiovascular events or stroke. Monitoring and managing blood pressure in clients experiencing alcohol withdrawal is crucial to prevent adverse outcomes. Tremors, nausea and vomiting, and insomnia are common symptoms of alcohol withdrawal, but they are not as immediately life-threatening as increased blood pressure. Therefore, addressing increased blood pressure takes precedence in the management of a client experiencing alcohol withdrawal.

2. A teenage boy is attracted to a female teacher. Without objective evidence, a school nurse overhears the boy state, 'I know she wants me.' This statement reflects which defense mechanism?

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

Correct answer: B

Rationale: The correct answer is B: Projection. The nurse should determine that the client's statement reflects the defense mechanism of projection. Projection refers to the attribution of one's unacceptable feelings or impulses to another person. In this case, the boy is projecting his own desires onto the female teacher, believing that she wants him. By externalizing his feelings, the boy reduces his anxiety and discomfort about his own attraction. Displacement involves transferring emotions from one target to another, not attributing one's own feelings to others. Rationalization involves creating logical explanations for unacceptable behaviors, not projecting feelings onto others. Sublimation is the channeling of unacceptable impulses into socially acceptable actions, which is not demonstrated in this scenario.

3. A client is diagnosed with obsessive-compulsive disorder (OCD). Which of the following interventions should the nurse include in the care plan? Select one that does not apply.

• A. Allow the client to perform rituals initially
• B. Set limits on the time allowed for rituals
• C. Encourage the client to verbalize feelings
• D. Provide a structured schedule of activities

Correct answer: A

Rationale: Interventions for a client with OCD should include allowing the client to perform rituals initially, setting limits on the time allowed for rituals, encouraging the client to verbalize feelings, and providing a structured schedule of activities. Allowing the client to perform rituals is an essential part of managing OCD and should not be restricted in the initial stages of care. Setting limits on the time for rituals helps prevent excessive engagement in them. Encouraging the client to verbalize feelings promotes emotional expression and processing. Providing a structured schedule of activities helps establish routine and predictability, which can be beneficial for individuals with OCD.

4. Tomas is a 21-year-old male with a recent diagnosis of schizophrenia. Tomas's nurse recognizes that self-medicating with excessive alcohol is common in this disease and can co-occur along with:

• A. Generally good health despite the mental illness.
• B. An aversion to drinking fluids.
• C. Anxiety and depression.
• D. The ability to express his needs.

Correct answer: C

Rationale: Individuals with schizophrenia often turn to excessive alcohol consumption as a way to manage symptoms of anxiety and depression. This maladaptive coping mechanism can exacerbate the challenges associated with schizophrenia and may hinder effective treatment outcomes. Recognizing the presence of anxiety and depression alongside alcohol abuse is crucial for providing holistic care and support to individuals with schizophrenia.

5. Which approach involves surgically implanting electrodes into specific areas of the brain to stimulate regions identified as underactive in depression?

• A. Transcranial magnetic stimulation
• B. Deep brain stimulation
• C. Vagus nerve stimulation
• D. Electroconvulsive therapy

Correct answer: B

Rationale: Deep brain stimulation is a treatment approach that involves the surgical implantation of electrodes into specific areas of the brain to stimulate regions identified as underactive in depression. This method aims to modulate brain activity and has shown effectiveness in treating certain cases of depression.

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