Nursing Elites

1. Maggie, a child in protective custody, is found to have an imaginary friend, Holly. Her foster family shares this information with the nurse. The nurse teaches the family members about children who have suffered trauma and knows her teaching was effective when the foster mother states:

• A. I understand that imaginary friends are abnormal.
• B. I understand that imaginary friends are a maladaptive behavior.
• C. I understand that imaginary friends are a coping mechanism.
• D. I understand that we should tell the child that imaginary friends are unacceptable.

Correct answer: C

Rationale: Imaginary friends can serve as a coping mechanism for children, especially those who have experienced trauma. They can provide comfort and a sense of control in challenging situations. Acknowledging and supporting the child's imaginary friend can be beneficial in their emotional healing and development.

2. A client has been prescribed escitalopram (Lexapro) for depression. Which instruction should the nurse include in the discharge teaching?

• A. Take the medication at bedtime to prevent daytime drowsiness.
• B. Avoid consuming alcohol while taking this medication.
• C. Take the medication with food to prevent stomach upset.
• D. Discontinue the medication if you start feeling better.

Correct answer: B

Rationale: The correct instruction for the nurse to include in the discharge teaching is to advise the client to avoid consuming alcohol while taking escitalopram (Lexapro). Alcohol can potentiate side effects such as drowsiness and dizziness when combined with this medication. Choice A is incorrect because escitalopram is usually taken in the morning due to its potential to cause insomnia if taken at bedtime. Choice C is incorrect because taking the medication with or without food does not significantly affect its absorption or side effects. Choice D is incorrect because it is essential for the client to continue taking the medication even if they start feeling better, as abruptly stopping an antidepressant can lead to withdrawal symptoms and a relapse of depression.

3. In what significant way should the therapeutic environment differ for a client who has ingested LSD from that of a client who has ingested PCP?

• A. For LSD ingestion, maintain a regimen of limited interaction and minimal verbal stimulation. For PCP ingestion, place client on one-on-one intensive supervision.
• B. For LSD ingestion, place the client in restraints. For PCP ingestion, place the client on seizure precautions.
• C. For LSD ingestion, provide continual medieval simulation involving as many senses as possible. For PCP ingestion, provide continual high-level stimulation.
• D. For PCP ingestion, place the client on one-on-one intensive supervision. For LSD ingestion, maintain a regimen of limited interaction and minimal verbal stimulation.

Correct answer: D

Rationale: When managing a client who has ingested PCP, it is crucial to provide one-on-one intensive supervision to ensure their safety and prevent any harm to themselves or others. This level of supervision is necessary due to the unpredictable and potentially dangerous effects of PCP. On the other hand, for a client who has ingested LSD, it is recommended to maintain a calm environment with limited interaction and minimal verbal stimulation. This approach aims to prevent exacerbating any adverse effects of LSD, such as anxiety or paranoia, by reducing external stimuli. Therefore, the correct approach is to provide one-on-one intensive supervision for PCP ingestion and limit interaction and verbal stimulation for LSD ingestion.

4. Which statement made by the patient demonstrates an understanding of the treatment of choice for patients managing the effects of traumatic events?

• A. I attend my therapy sessions regularly.
• B. Those intrusive memories are hidden for a reason and should stay hidden.
• C. Keeping busy is the key to achieving mental health.
• D. I've agreed to move in with my parents so I'll get the support I need.

Correct answer: A

Rationale: Regular attendance at therapy sessions is a crucial aspect of the recommended treatment for managing the effects of traumatic events. Therapy provides a safe space for individuals to process their experiences, develop coping strategies, and work towards healing and recovery. Consistent participation in therapy sessions can help patients address and overcome the impact of trauma on their mental health.

5. Which symptom should a healthcare provider identify as typical of the fight-or-flight response?

• A. Pupil dilation
• B. Increased heart rate
• C. Decreased salivation
• D. Decreased peristalsis

Correct answer: B

Rationale: The correct answer is B: Increased heart rate. During the fight-or-flight response, the sympathetic nervous system is activated, causing the release of epinephrine. This hormone triggers an increase in heart rate to supply more blood to the muscles for a rapid response. Pupil dilation occurs to enhance vision in preparation for quick reactions. On the other hand, salivation and peristalsis decrease as the body prioritizes functions necessary for immediate action rather than digestion-related activities. Therefore, choices A, C, and D are incorrect as they do not align with the typical physiological changes associated with the fight-or-flight response.

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