Nursing Elites

1. The nurse has just admitted a client with severe depression. From which focus should the nurse identify a priority nursing diagnosis?

• A. Nutrition
• B. Elimination
• C. Activity
• D. Safety

Correct answer: D

Rationale: In caring for a client with severe depression, ensuring safety is a top priority. Suicide prevention measures must be incorporated into the care plan as individuals with depression are at increased risk. While nutrition, elimination, and activity are important aspects of care, safety takes precedence due to the critical need to prevent harm or self-harm in depressed individuals.

2. During her shift at the hospital, a nurse receives a stern reprimand from a physician over something over which she had no control. The nurse does not respond. When she returns home that evening, she sees her children's toys all over the floor, gets mad, and begins to yell at them. Which form of defense mechanism is this nurse using?

• A. Symbolization
• B. Suppression
• C. Displacement
• D. Projection

Correct answer: C

Rationale: Displacement is the process of redirecting feelings or impulses from one person to another. In this scenario, the nurse chose not to respond to the physician, but instead displaced her negative emotions onto her children, who are less threatening and more vulnerable. This defense mechanism allowed her to express her anger in a safer outlet. Symbolization involves representing unconscious feelings or impulses through symbols, not redirecting them. Suppression is the conscious effort to push unwanted thoughts or feelings out of awareness, not displacing them onto others. Projection involves attributing one's thoughts or emotions to someone else, which is not evident in this case.

3. Which of the following is an example of non-reversible dementia?

• A. Pick's disease
• B. Syphilis
• C. Encephalopathy
• D. Hyperthyroidism

Correct answer: A

Rationale: Non-reversible dementia refers to a condition where individuals experience permanent and often progressive cognitive decline. Pick's disease is a type of non-reversible dementia characterized by changes in personality, behavior, and language difficulties. Syphilis (Choice B) is a reversible cause of dementia that can be treated with antibiotics. Encephalopathy (Choice C) is a broad term for brain dysfunction that can be reversible or irreversible depending on the cause. Hyperthyroidism (Choice D) can lead to cognitive impairment but is reversible with appropriate treatment. Therefore, Pick's disease is the correct example of non-reversible dementia among the options provided.

4. Ten minutes after signing an operative permit for a fractured hip, an older client states, 'The aliens will be coming to get me soon!' and falls asleep. Which action should the nurse implement next?

• A. Make the client comfortable and allow the client to sleep.
• B. Assess the client's neurologic status.
• C. Notify the surgeon about the comment.
• D. Ask the client's family to co-sign the operative permit.

Correct answer: B

Rationale: The client's statement about aliens coming to get them could indicate confusion, which raises concerns about their neurologic status. Since informed consent for surgery requires the client to be mentally competent, the nurse should assess the client's neurologic status to ensure they understand and can legally provide consent. Option A of making the client comfortable and letting them sleep does not address the potential neurologic issue. If the nurse finds the client to be confused, it is essential to inform the surgeon and seek permission from the next of kin if necessary. Therefore, assessing the client's neurologic status is the priority to ensure the client's ability to consent to the surgery.

5. Which instruction is most important for the nurse to include when teaching a client with limited mobility strategies to prevent venous thrombosis?

• A. Perform cough and deep breathing exercises hourly.
• B. Turn from side to side in bed at least every 2 hours.
• C. Dorsiflex and plantarflex the feet 10 times each hour
• D. Drink approximately 4 ounces of water every hour

Correct answer: C

Rationale: To reduce the risk of venous thrombosis, the nurse should instruct the client to perform dorsiflexion and plantar flexion exercises regularly. These exercises help promote venous return and prevent venous thrombus formation. Options A, B, and D are beneficial in managing other complications of immobility, such as atelectasis and pressure ulcers, but they are less effective in preventing venous thrombosis compared to dorsiflexion and plantar flexion exercises.

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