Nursing Elites

1. The client with a myocardial infarction comes to the nurse's station stating that he is ready to go home because there is nothing wrong with him. Which defense mechanism is the client using?

• A. Rationalization
• B. Denial
• C. Projection
• D. Conversion reaction

Correct answer: B

Rationale: The correct answer is B: Denial. The client displaying denial refuses to acknowledge the reality of having a myocardial infarction. Rationalization (choice A) involves making excuses for behavior, not denying a condition. Projection (choice C) is attributing one's thoughts or feelings to others, not denying an illness. Conversion reaction (choice D) is converting psychological distress into physical symptoms, which is not evident in this scenario. Therefore, denial is the defense mechanism being used in this situation.

2. While walking in the hallway of an acute care unit of the hospital, the nurse overhears the change of shift report. What should the nurse do?

• A. Make the charge nurse on the unit aware of the situation so that they can take the necessary steps to maintain the confidentiality of the information being reported.
• B. Disregard the information because it changes quickly on the acute care unit and is outdated within 2-3 hours anyway.
• C. Return to their own unit and not disclose that confidential information has been overheard.
• D. Ignore the situation.

Correct answer: A

Rationale: To protect the confidentiality of the information being reported, the nurse should make the charge nurse on the unit aware of the situation. This allows the charge nurse to take necessary steps to maintain confidentiality and ensure that the information is communicated in an appropriate and private manner. Disclosing the situation to the charge nurse is essential to address any breaches in confidentiality and uphold professional standards of privacy and ethics. Disregarding the information, returning to their own unit without disclosure, or ignoring the situation altogether would not address the breach of confidentiality and could lead to further issues regarding patient privacy and trust.

3. What is the first exercise that should be performed by a client who had a mastectomy?

• A. Walking the hand up the wall
• B. Sweeping the floor
• C. Combing her hair
• D. Squeezing a ball

Correct answer: D

Rationale: The correct answer is D: Squeezing a ball. The first exercise that should be done by a client with a mastectomy is squeezing a ball. This helps in regaining strength and mobility in the affected area. Choices A, B, and C are incorrect as they are not typically the initial exercises recommended post-mastectomy. Walking the hand up the wall, sweeping the floor, and combing hair are activities that may be introduced later in the rehabilitation process.

4. Which of the following factors can impact an individual's ability to give informed consent?

• A. IQ
• B. educational level
• C. pain medications
• D. financial status

Correct answer: C

Rationale: Pain medications might alter alertness, thought processes, and reactions, potentially impacting an individual's ability to give informed consent. It is recommended to approach a client for consent at least 4 hours after the last dose of pain medicine to minimize any influence. Choices A, B, and D are incorrect. While IQ and educational level may affect how information is presented during the discussion process, they do not directly impact informed-consent decision-making. Financial status is also not a direct factor in an individual's ability to provide informed consent, unlike pain medications which can directly affect cognitive functions and decision-making abilities.

5. What is a common characteristic of a batterer?

• A. Grew up in a loving, secure home
• B. Was an only child
• C. Was physically or psychologically abused
• D. Admits they have a problem with anger

Correct answer: C

Rationale: The correct answer is that a batterer is typically someone who was physically or psychologically abused. Research shows that many individuals who engage in abusive behavior report a history of being abused themselves. Choices A, B, and D are incorrect. While it is possible for a batterer to have grown up in a loving, secure home, been an only child, or acknowledge their anger issues, the most common factor associated with becoming a batterer is a history of being abused.

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