Nursing Elites

1. At the first meeting of a group of older adults at a daycare center for the elderly, the nurse asks one of the members what kinds of things she would like to do with the group. The older woman shrugs her shoulders and says, 'You tell me, you're the leader.' What is the best response for the nurse to make?

• A. 'Yes, I am the leader today. Would you like to be the leader tomorrow?'
• B. 'Yes, I will be leading this group. What would you like to accomplish during this time?'
• C. 'Yes, I have been assigned to be the leader of this group. I will be here for the next six weeks.'
• D. 'Yes, I am the leader. You seem angry about not being the leader yourself.'

Correct answer: B

Rationale: (B) provides information and focuses the group back to defining its function. (A) is manipulative bargaining. (C) does not focus on the group’s purpose. (D) challenges the client’s feelings.

2. The nurse plans to help an 18-year-old female intellectually disabled client ambulate on the first postoperative day after an appendectomy. When the nurse tells the client it is time to get out of bed, the client becomes angry and tells the nurse, 'Get out of here! I'll get up when I'm ready!' Which response is best for the nurse to make?

• A. Your healthcare provider has prescribed ambulation on the first postoperative day.
• B. You must ambulate to avoid complications that could cause more discomfort than ambulating.
• C. I know how you feel. You're angry about having to ambulate, but this will help you get well.
• D. I'll be back in 30 minutes to help you get out of bed and walk around the room.

Correct answer: D

Rationale: (D) provides a 'cooling off' period, is firm, direct, non-threatening, and avoids arguing with the client. (A) is avoiding responsibility by referring to the healthcare provider. (B) is trying to reason with an intellectually disabled client and is threatening the client with 'complications.' (C) is telling the client how she feels (angry), and the nurse does not really 'know' how this client feels, unless the nurse is also intellectually disabled and has also just had an appendectomy.

3. The LPN/LVN is caring for a client with depression who has been prescribed an SSRI. The client reports feeling more energy but is still feeling hopeless. What should the nurse be most concerned about?

• A. That the client may act on suicidal thoughts.
• B. That the client may engage in impulsive behavior.
• C. That the client may be experiencing the side effects of the medication.
• D. That the client may be at risk for developing serotonin syndrome.

Correct answer: A

Rationale: The nurse should be most concerned that the client may act on suicidal thoughts. An increase in energy combined with persistent feelings of hopelessness can indicate a higher risk of suicide. While impulsive behavior can be a concern, the primary worry should be the client's safety regarding suicidal ideation. Side effects of the medication are important to monitor but do not take precedence over the risk of self-harm. Serotonin syndrome is a potential concern with SSRIs, but in this scenario, the client's mental health and safety are the immediate priority.

4. A client is responding to auditory hallucinations and shakes a fist at a nurse and says, 'Back off, witch!' The nurse follows the client into the day room. What action should the nurse implement?

• A. Sit down in a chair near the client.
• B. Position self within an arm's length of the client.
• C. Ensure that there is physical space between the nurse and client.
• D. Move to a position that allows the client to be closest to the room's door.

Correct answer: C

Rationale: In situations where a client is responding to auditory hallucinations and displaying aggressive behavior, it is crucial for the nurse to ensure physical space between themselves and the client. This action can help de-escalate the situation and prevent any potential harm to both the nurse and the client. Sitting down near the client (Choice A) may escalate the situation by invading the client's personal space. Positioning oneself within an arm's length of the client (Choice B) may increase the risk of physical confrontation. Moving closer to the room's door (Choice D) may not be appropriate as it can block the client's exit route and escalate the situation further. Therefore, ensuring physical space between the nurse and the client (Choice C) is the most appropriate action to promote safety and prevent escalation.

5. A client on the psychiatric unit appears to imitate a certain nurse on the unit. The client seeks out this particular nurse and imitates the nurse's mannerisms. The nurse knows that the client is using which defense mechanism?

• A. Sublimation.
• B. Identification.
• C. Introjection.
• D. Repression.

Correct answer: B

Rationale: The correct answer is (B) Identification. In this scenario, the client is imitating the nurse's mannerisms, which is a form of identification, a defense mechanism where an individual adopts the characteristics or behaviors of someone they admire or view as powerful. (A) Sublimation involves channeling unacceptable impulses into socially acceptable actions, not imitation. (C) Introjection is the internalization of external qualities or attributes, not imitation. (D) Repression is the unconscious exclusion of painful thoughts or memories from awareness, which is not demonstrated in this case.

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