Nursing Elites

1. The client with diabetes is preparing for discharge. During discharge teaching, the nurse assesses the client's ability to care for himself. Which statement made by the client would indicate a need for follow-up after discharge?

• A. "I live by myself."?
• B. "I have trouble seeing."?
• C. "I have a cat in the house with me."?
• D. "I usually drive myself to the doctor."?

Correct answer: B

Rationale: A client with diabetes who has trouble seeing would require follow-up after discharge. The lack of visual acuity for the client preparing and injecting insulin might require help. Answers A, C, and D will not prevent the client from being able to care for himself and are incorrect. Living alone (Choice A) does not necessarily indicate a need for follow-up unless there are specific concerns. Having a cat at home (Choice C) and driving to the doctor (Choice D) are not direct indicators of the client's ability to care for himself.

2. 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.

3. An adolescent female reports being raped at a party where alcohol was served. The client admits to drinking alcohol before being raped by an acquaintance. The nurse should:

• A. inform the client that because she is underage, she is not at fault for attending a party where alcohol was served.
• B. ask the client if anyone witnessed the event because the client was intoxicated and might not remember it accurately.
• C. inform the client that it was not her fault, and support the client through the physical examination.
• D. question whether the woman had consensual sex and now just feels guilty.

Correct answer: C

Rationale: In cases of rape, it is crucial to provide support and reassurance to the victim. The nurse should inform the client that it was not her fault and offer support through the physical examination. Blaming the victim, as in choice A, is inappropriate and can be damaging to the client's well-being. Choice B is not the priority at this moment; the immediate focus should be on supporting the client. Choice D is victim-blaming and implies doubt about the client's report, which is harmful and not supportive. It is essential to create a safe and supportive environment for the client to facilitate healing and recovery.

4. What type of relief behavior is Ashley using to cope with emotional conflict?

• A. acting out
• B. somatizing
• C. withdrawal
• D. problem-solving

Correct answer: B

Rationale: Ashley is somatizing by experiencing emotional conflict as physical symptoms associated with severe anxiety. Somatizing involves converting emotions into physical symptoms. Acting out involves behaviors like anger, crying, and verbal abuse, not physical symptoms. Withdrawal is when one withdraws psychic energy in response to anxiety, not converting emotions into physical symptoms. Problem-solving occurs when anxiety is identified and the underlying need is addressed, not converting emotions into physical symptoms.

5. The primary organ for drug elimination is the:

• A. skin
• B. lung(s)
• C. kidney(s)
• D. liver

Correct answer: C

Rationale: The correct answer is the kidney(s) because most drugs are excreted in the urine, either as the parent compound or as drug metabolites. The skin is not the primary organ for drug elimination; only a few drugs are excreted in sweat. The lung(s) primarily excrete volatile gases with expiration, not drugs. While the liver metabolizes drugs, it is the kidney(s) that primarily eliminate drugs through urine, especially those with a molecular weight above 300.

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