Nursing Elites

1. A nurse is providing education to a client who has been prescribed lithium for bipolar disorder. Which statement by the client indicates an accurate understanding of the medication?

• A. I should avoid eating aged cheeses and processed meats.
• B. I need to maintain a consistent sodium intake.
• C. I should drink plenty of fluids to stay hydrated.
• D. I can take over-the-counter medications without consulting my doctor.

Correct answer: B

Rationale: Clients taking lithium should maintain a consistent sodium intake to avoid fluctuations in lithium levels.

2. Which characteristic presents the greatest risk for injury to others in a patient diagnosed with schizophrenia?

• A. Depersonalization
• B. Pressured speech
• C. Negative symptoms
• D. Paranoia

Correct answer: D

Rationale: Paranoia in patients with schizophrenia can lead to aggressive behaviors, including violence, which poses a significant risk of injury to others. Individuals experiencing paranoia may perceive others as threats and act defensively or aggressively in response, increasing the likelihood of harm to those around them.

3. Which client action is an example of the defense mechanism of reaction formation?

• A. A woman who feels unattractive constantly praises the looks of others.
• B. A man who feels insecure about his masculinity exaggerates his strength.
• C. A person who feels guilty about cheating accuses others of being unfaithful.
• D. A child who feels neglected tries to win approval from teachers.

Correct answer: A

Rationale: The defense mechanism of reaction formation involves expressing the opposite of one's true feelings. In this case, the woman who feels unattractive praises the looks of others as a way to mask her own feelings of inadequacy. This behavior represents a form of overcompensation where the individual showcases an exaggerated opposite trait to conceal their true emotions. Choices B, C, and D do not align with reaction formation. Choice B describes compensation, where one overemphasizes a trait to make up for a perceived weakness. Choice C illustrates projection, where one attributes their feelings onto others. Choice D demonstrates a form of seeking attention or approval, which does not fit reaction formation.

4. A client with major depressive disorder is prescribed an antidepressant. Which of the following instructions should the nurse exclude from the teaching?

• A. It may take several weeks for the medication to take effect
• B. Avoid alcohol while taking this medication
• C. Discourage the client from washing her hands
• D. You may experience an increase in energy before your mood improves

Correct answer: C

Rationale: The nurse should not include the instruction to discourage the client from washing her hands in the teaching for a client prescribed an antidepressant. This instruction is not relevant to the medication regimen. Instead, the nurse should educate the client that it may take several weeks for the medication to take effect, to avoid alcohol, not to discontinue the medication abruptly, and that there may be an increase in energy before mood improves. Regular blood tests are not typically required for most antidepressants.

5. A client diagnosed with post-traumatic stress disorder (PTSD) is being assessed by a healthcare professional. Which symptom would the healthcare professional expect the client to exhibit?

• A. Delusions of grandeur
• B. Hypervigilance
• C. Obsessive-compulsive behaviors
• D. Periods of excessive sleeping

Correct answer: B

Rationale: In individuals with post-traumatic stress disorder (PTSD), hypervigilance is a common symptom. Hypervigilance refers to a state of increased alertness, awareness, and sensitivity to potential threats or danger. This heightened state of vigilance can manifest as being easily startled, having difficulty relaxing or sleeping, and constantly scanning the environment for signs of danger. It is an adaptive response to the trauma experienced and can significantly impact the individual's daily functioning. The other options are not typically associated with PTSD. Delusions of grandeur are more commonly seen in certain psychiatric disorders like bipolar disorder or schizophrenia. Obsessive-compulsive behaviors are characteristic of obsessive-compulsive disorder (OCD), not PTSD. Periods of excessive sleeping may be seen in conditions like depression, but they are not a hallmark symptom of PTSD.

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