Nursing Elites

1. 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.

2. A client with bipolar disorder is prescribed lithium. Which of the following statements by the client indicates a need for further teaching?

• A. I should maintain a consistent salt intake.
• B. I should drink 6-8 glasses of water daily.
• C. I need to have my lithium levels checked regularly.
• D. I can stop taking my medication once my mood stabilizes.

Correct answer: D

Rationale: The statement "I can stop taking my medication once my mood stabilizes" indicates a need for further teaching. Clients should continue taking their medication as prescribed and have regular monitoring of lithium levels.

3. A client is experiencing panic attacks. Which intervention should the nurse implement to help the client manage anxiety?

• A. Encourage the client to avoid situations that trigger anxiety.
• B. Encourage the client to practice deep breathing exercises.
• C. Encourage the client to take anti-anxiety medication as prescribed.
• D. Encourage the client to engage in regular physical activity.

Correct answer: B

Rationale: During panic attacks, deep breathing exercises can help the client manage anxiety effectively by promoting relaxation and reducing the intensity of symptoms. Encouraging the client to practice deep breathing can provide a quick and accessible strategy to cope with the immediate distress of a panic attack. Choices A, C, and D are incorrect because avoiding triggering situations may reinforce avoidance behavior, anti-anxiety medication is not the first-line intervention during a panic attack, and engaging in physical activity may not be feasible or effective during an acute episode of panic.

4. During a panic attack, what is the nurse's priority intervention for a patient with panic disorder?

• A. Encourage the patient to verbalize their feelings.
• B. Provide reassurance and stay with the patient.
• C. Leave the patient alone to calm down.
• D. Distract the patient with a task.

Correct answer: B

Rationale: During a panic attack, the priority intervention for the nurse is to provide reassurance and stay with the patient. This action helps reduce fear and provides a sense of safety, which can aid in calming the patient and preventing further escalation of the panic attack. Encouraging the patient to verbalize their feelings (Choice A) may be beneficial after the acute phase of the panic attack. Leaving the patient alone (Choice C) may increase feelings of abandonment and escalate the panic attack. Distracting the patient with a task (Choice D) is not recommended during a panic attack as it may divert attention but not address the underlying anxiety and fear.

5. A client who experiences stress on a regular basis asks a nurse what causes these feelings. Which is the most appropriate nursing response?

• A. Genetics have no influence on your temperament.
• B. How you reacted to past experiences influences how you feel now.
• C. Maintaining good physical health always keeps stress levels low.
• D. Stress can be avoided by using appropriate coping mechanisms.

Correct answer: B

Rationale: The correct answer is B: 'How you reacted to past experiences influences how you feel now.' This response is appropriate because past experiences can shape an individual's current response to stress. It acknowledges the impact of learned patterns and coping mechanisms on one's current adaptation to stressors. Choice A is incorrect because genetics can play a role in temperament to some extent. Choice C is incorrect because while physical health can contribute to stress management, it is not the sole determinant of stress levels. Choice D is incorrect as stress is not always avoidable, but coping mechanisms can help manage and reduce its impact.

Similar Questions