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. Which of the following is an advantage of working with psychiatric clients in a group setting?

• A. Clients assist each other through therapeutic interventions with the support of a nurse
• B. Clients can receive peer support and feedback in a safe and controlled environment
• C. Clients can share experiences and coping strategies while maintaining confidentiality
• D. Clients learn from others when their behaviors are inappropriate in a safe and trusting environment

Correct answer: D

Rationale: Group therapy is a valuable approach in mental health treatment. Working with psychiatric clients in a group setting offers various benefits. Clients in a group setting can learn from others when their behaviors are inappropriate in a safe and trusting environment. This environment allows individuals to express thoughts and feelings without fear of judgment or criticism, fostering a supportive atmosphere. Through interactions with peers, clients can gain insight into their own behaviors and learn alternative ways of coping. Choice A is incorrect as the presence and support of a nurse are typically important in group therapy sessions. Choice B is incorrect as group settings provide structure and rules to ensure a safe space for clients to express themselves. Choice C is incorrect as maintaining confidentiality is crucial in group therapy to build trust and encourage open sharing.

3. The wife of a client who is dying says, 'I want to see him, but I can only come twice a week because of work, household chores, and caring for our cat and dog.' Which defense mechanism is the wife using?

• A. Projection
• B. Sublimation
• C. Compensation
• D. Rationalization

Correct answer: D

Rationale: The wife is using rationalization as a defense mechanism. Rationalization involves offering a socially acceptable or logical explanation to justify an unacceptable feeling or behavior. In this scenario, the wife justifies her limited visits to her dying husband by citing other responsibilities such as work, household chores, and pet care. Projection involves denying one's unacceptable feelings and attributing them to others. Sublimation is the substitution of unacceptable feelings or drives with socially acceptable behaviors. Compensation involves making up for a perceived deficiency by emphasizing another perceived asset.

4. A woman who had a mastectomy is scheduled for a mastectomy peer support visit arranged by her primary health care provider. What is the purpose of the referral?

• A. To teach arm exercises
• B. To prevent social isolation
• C. To meet her physical needs
• D. To view her surgical incision

Correct answer: B

Rationale: The purpose of a mastectomy peer support visit is to prevent social isolation. This visit helps the client maintain her social connections and learn about community resources. Teaching arm exercises and meeting physical needs are tasks for healthcare professionals, not the primary goal of a peer support visit. Viewing the surgical incision is also not the primary purpose of such a visit.

5. When assessing an older adult, which vital sign changes would the nurse recognize as occurring with aging?

• A. Increase in pulse rate
• B. Widened pulse pressure
• C. Increase in body temperature
• D. Decrease in diastolic blood pressure

Correct answer: B

Rationale: When assessing an older adult, the nurse should be aware that with aging, systolic blood pressure tends to increase, resulting in widened pulse pressure. While in many older individuals both systolic and diastolic pressures increase, the pulse rate and body temperature typically do not increase with aging. Therefore, the correct answer is widened pulse pressure. Choices A, C, and D are incorrect because pulse rate does not necessarily increase with age, body temperature generally remains stable, and diastolic blood pressure may increase instead of decreasing in many older adults.

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