Nursing Elites

1. The client is taking rifampin 600mg po daily to treat his tuberculosis. Which action by the nurse indicates understanding of the medication?

• A. Telling the client that the medication will need to be taken with juice
• B. Telling the client that the medication will change the color of the urine
• C. Telling the client to take the medication before going to bed at night
• D. Telling the client to take the medication if night sweats occur

Correct answer: B

Rationale: The correct answer is telling the client that the medication will change the color of the urine. Rifampin can change the color of the urine and body fluid. Teaching the client about these changes is important as the client might think this is a complication. Answer A is incorrect because there is no specific requirement to take rifampin with juice. Answer C is incorrect because rifampin should be taken at consistent times, not necessarily before going to bed. Answer D is incorrect as rifampin should be taken regularly as prescribed, not based on symptoms like night sweats.

2. Ashley and her boyfriend Chris, both 19 years old, are transported to the Emergency Department after being involved in a motorcycle accident. Chris is badly hurt, but Ashley has no apparent injuries, though she appears confused and has trouble focusing on what is going on around her. She complains of dizziness and nausea. Her pulse is rapid, and she is hyperventilating. The nurse should assess Ashley's level of anxiety as:

• A. mild.
• B. moderate.
• C. severe.
• D. panic.

Correct answer: C

Rationale: Explanation: Ashley is displaying symptoms of severe anxiety, including confusion, trouble focusing, dizziness, nausea, rapid pulse, and hyperventilation. These somatic symptoms, along with changes in vital signs, indicate severe anxiety. In severe anxiety, individuals are unable to solve problems and have a poor grasp of their environment. On the other hand, mild anxiety may lead to mild discomfort or even enhanced performance, while moderate anxiety results in difficulty grasping information and minor changes in vital signs. Panic, the most severe level of anxiety, involves markedly disturbed behavior and a potential loss of touch with reality. Therefore, based on Ashley's symptoms, her anxiety level should be assessed as severe.

3. James returns home from school angry and upset because his teacher gave him a low grade on an assignment. After returning home from school, he kicks the dog. This coping mechanism is known as:

• A. denial
• B. suppression
• C. displacement
• D. fantasy

Correct answer: C

Rationale: Displacement is the transference of emotions, such as anger, to a substitute target that may be less threatening. In this scenario, James redirects his anger from the teacher to the dog. Denial is refusing to acknowledge an aspect of reality. Suppression is consciously putting aside unwanted thoughts or feelings. Fantasy involves imagining unrealistic scenarios. Therefore, in this case, the correct answer is displacement as James displaces his anger towards the dog.

4. When the nurse who was not promoted first read the memo and learned that the other nurse had received the promotion, she left the room in tears. This behavior is an example of:

• A. conversion.
• B. regression
• C. introjection.
• D. rationalization

Correct answer: B

Rationale: Crying is a regressive behavior. The ego returned to an earlier, comforting, and less-mature way of behaving in the face of disappointment. Regression involves reverting to an earlier stage of development to cope with stress or conflict. In this scenario, the nurse regressed to a childlike state by crying when faced with the disappointment of not getting the promotion, demonstrating regression as a defense mechanism. Conversion involves transforming anxiety into a physical symptom. Introjection involves unconsciously identifying intensely with another person. Rationalization involves unconsciously creating acceptable explanations to justify unacceptable ideas, actions, or feelings. Therefore, the correct answer is regression as it aligns with the nurse's behavior of regressing to a childlike state by crying due to the disappointment of not receiving the promotion.

5. A client is admitted to the acute care unit. Initial laboratory values reveal serum sodium of 170meq/L. What behavior changes would be most common for this client?

• A. Anger
• B. Mania
• C. Depression
• D. Psychosis

Correct answer: B

Rationale: The correct answer is 'Mania.' A client with a serum sodium level of 170 meq/L has hypernatremia, which can lead to manic behavior. Hypernatremia is associated with irritability, restlessness, confusion, and in severe cases, manic symptoms. Choices A, C, and D (Anger, Depression, Psychosis) are not typically associated with hypernatremia and are, therefore, incorrect in this context.

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