Nursing Elites

1. A student finds that they come down with a sinus infection toward the end of every semester. When this occurs, which stage of stress is the student most likely experiencing?

• A. Alarm reaction stage
• B. Stage of resistance
• C. Stage of exhaustion
• D. Fight-or-flight stage

Correct answer: C

Rationale: The student is most likely experiencing the stage of exhaustion. In this stage, the body's exposure to stress has been prolonged, and adaptive energy has been depleted. As a result, diseases of adaptation, such as the recurrent sinus infection in this case, are more likely to occur. The alarm reaction stage is the initial stage of the stress response, where the body perceives a threat and activates the fight-or-flight response. The stage of resistance is when the body tries to adapt and cope with the stressor. The fight-or-flight response is the immediate reaction to a perceived threat, involving physiological changes to prepare the body to either fight the stressor or flee from it.

2. A client with obsessive-compulsive disorder (OCD) is being cared for by a nurse. Which intervention should the nurse implement to help the client manage compulsive behaviors?

• A. Encourage the client to suppress compulsive behaviors.
• B. Allow the client to perform compulsive behaviors with limits.
• C. Teach the client relaxation techniques to manage anxiety.
• D. Discourage the client from performing compulsive behaviors.

Correct answer: B

Rationale: Allowing the client to perform compulsive behaviors with limits is a therapeutic intervention for managing OCD. This approach grants the client some autonomy while ensuring that the behaviors do not excessively disrupt daily life. Setting boundaries helps structure the behaviors, decreasing anxiety and distress associated with OCD. Encouraging the client to suppress compulsive behaviors (choice A) may lead to increased anxiety and potential worsening of symptoms. Teaching relaxation techniques (choice C) is beneficial for managing anxiety in general but may not directly address the compulsive behaviors. Discouraging the client from performing compulsive behaviors (choice D) without providing alternative strategies or support may increase distress and resistance.

3. What intervention should the nurse implement for a client with obsessive-compulsive disorder (OCD) performing ritualistic handwashing?

• A. Allow the client to continue the ritualistic behavior initially
• B. Immediately stop the client from performing the ritual
• C. Encourage the client to perform the ritual more quickly
• D. Provide a distraction to interrupt the ritual

Correct answer: A

Rationale: For a client with OCD performing ritualistic handwashing, the nurse should initially allow the client to continue the behavior. Abruptly stopping the behavior or providing a distraction can heighten the client's anxiety. Encouraging the client to perform the ritual more quickly does not address the underlying issue of OCD and may exacerbate their anxiety. Providing a distraction to interrupt the ritual may not be effective in the long term and could lead to increased distress. Gradual limits should be established over time to help the client manage and reduce the ritualistic behavior effectively.

4. Which of the following statements should a healthcare professional recognize as true about defense mechanisms? Select the one that doesn't apply.

• A. They are employed when there is a threat to biological or psychological integrity.
• B. They are controlled by the id and deal with primal urges.
• C. They are used in an effort to relieve mild to moderate anxiety.
• D. They are protective devices for the superego.

Correct answer: B

Rationale: Defense mechanisms are employed by the ego in the face of threats to biological and psychological integrity to relieve mild to moderate anxiety. They act as protective devices for the ego, not the id or superego. The id represents primal instincts, while the superego is associated with moral standards. Defense mechanisms help individuals cope with stressors by redirecting focus and are often unconscious and self-deceptive.

5. When assessing a client experiencing severe anxiety, which symptom should the nurse expect to observe?

• A. Restlessness
• B. Rapid heart rate
• C. Sweating
• D. Dry mouth

Correct answer: B

Rationale: When a client is experiencing severe anxiety, a rapid heart rate is a common physiological response. This increased heart rate is due to the body's fight-or-flight response, where adrenaline is released, causing the heart to beat faster. Monitoring the client's heart rate is crucial in assessing and managing their anxiety. Restlessness (choice A) can also be present in anxiety but is more of a behavioral manifestation rather than a physiological symptom. Sweating (choice C) can occur in anxiety, but it is not as specific or consistent as a rapid heart rate. Dry mouth (choice D) is associated with anxiety but is not as immediate or directly linked to the body's physiological response to stress as a rapid heart rate.

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