Nursing Elites

1. A patient with major depression who has lost 20 pounds in one month, has chronic low self-esteem, and a plan for suicide. The patient has taken an antidepressant medication for 1 week. Which nursing intervention is most directly related to this outcome: 'Patient will refrain from gestures and attempts to harm self'?

• A. Implement suicide precautions.
• B. Frequently offer high-calorie snacks and fluids.
• C. Assist the patient to identify three personal strengths.
• D. Observe patient for therapeutic effects of antidepressant medication.

Correct answer: A

Rationale: Implementing suicide precautions is the most critical intervention in this scenario as it directly addresses the patient's safety and the prevention of self-harm. The patient's significant weight loss, chronic low self-esteem, suicide plan, and recent initiation of an antidepressant medication indicate a high risk of self-harm. Suicide precautions involve close monitoring, removing harmful objects, and ensuring a safe environment to prevent the patient from acting on suicidal thoughts. While offering high-calorie snacks and fluids, assisting the patient in identifying personal strengths, and observing for therapeutic effects of the antidepressant are important aspects of care, they do not directly address the immediate risk of self-harm that implementing suicide precautions does.

2. Which defense mechanism would the nurse conclude a female client with obsessive-compulsive disorder, who washes her hands more than 20 times a day, is using to ease anxiety?

• A. Undoing
• B. Projection
• C. Introjection
• D. Displacement

Correct answer: A

Rationale: The correct answer is 'Undoing.' Undoing is a defense mechanism where the individual tries to negate a previous act to relieve guilt or anxiety. In this case, the client washing her hands excessively is trying to 'undo' perceived contamination or guilt associated with not washing. Projection (choice B) involves attributing one's own unacceptable thoughts or impulses to others, which is not demonstrated in this scenario. Introjection (choice C) is the process of internalizing beliefs or values of others, which is also not applicable in this context. Displacement (choice D) involves redirecting emotions from one target to another, which does not align with the client's behavior of handwashing as a response to anxiety in this case.

3. Which therapeutic technique can the nurse use when an anxious client exhibits pressured and rambling speech?

• A. Touch
• B. Silence
• C. Focusing
• D. Summarizing

Correct answer: C

Rationale: Focusing is the appropriate therapeutic technique to use when an anxious client exhibits pressured and rambling speech. By focusing on one specific aspect, the intended meaning is easier to understand and helps the client stay on track. Touch is not recommended in this scenario as it can invade the client's personal space and potentially increase anxiety. Silence may allow the client to continue rambling without addressing the underlying concerns. Summarizing requires the identification and exploration of the client's concerns, which may be challenging when the speech is pressured and disorganized.

4. A client decides to have hospice care rather than undergo an extensive surgical procedure. Which ethical principle does the client's behavior illustrate?

• A. Justice
• B. Veracity
• C. Autonomy
• D. Beneficence

Correct answer: C

Rationale: The correct answer is 'Autonomy.' Autonomy refers to an individual's right to make decisions about their own care. In this scenario, the client is choosing hospice care over surgery, demonstrating their autonomy in making healthcare choices. Justice involves fairness and equality in the distribution of resources and services, which is not the primary ethical principle illustrated in this case. Veracity pertains to truthfulness and honesty, which is not directly related to the client's decision-making process. Beneficence refers to the duty to do good and act in the best interest of the patient, which is not the central ethical principle demonstrated by the client's decision for hospice care.

5. The wife of a client who is dying says, 'I want to see him, but I can only come twice a week because of work, household chores, and caring for our cat and dog.' Which defense mechanism is the wife using?

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

Correct answer: D

Rationale: The wife is using rationalization as a defense mechanism. Rationalization involves offering a socially acceptable or logical explanation to justify an unacceptable feeling or behavior. In this scenario, the wife justifies her limited visits to her dying husband by citing other responsibilities such as work, household chores, and pet care. Projection involves denying one's unacceptable feelings and attributing them to others. Sublimation is the substitution of unacceptable feelings or drives with socially acceptable behaviors. Compensation involves making up for a perceived deficiency by emphasizing another perceived asset.

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