Nursing Elites

1. The physician has prescribed tranylcypromine sulfate (Parnate) 10mg bid. The nurse should teach the client to refrain from eating foods containing tyramine because it may cause:

• A. Hypertension
• B. Hyperthermia
• C. Melanoma
• D. Urinary retention

Correct answer: A

Rationale: If the client eats foods high in tyramine, he might experience malignant hypertension. Tyramine is found in cheese, sour cream, Chianti wine, sherry, beer, pickled herring, liver, canned figs, raisins, bananas, avocados, chocolate, soy sauce, fava beans, and yeast. These episodes are treated with Regitine, an alpha-adrenergic blocking agent. Choices B, C, and D are unrelated to the question: Hyperthermia is excessive body temperature, melanoma is a type of skin cancer, and urinary retention is the inability to empty the bladder.

2. Two staff nurses were considered for promotion to head nurse. The promotion is announced via a memo on the unit bulletin board. The nurse who was not promoted tells a friend, "Oh, well, I really didn't want the job anyway."? This is an example of:

• A. rationalization.
• B. denial.
• C. projection.
• D. compensation.

Correct answer: A.

Rationale: This is an example of rationalization, specifically the sour grapes form, where the individual convinces themselves that they didn't want something after realizing they couldn't have it. Rationalization is an unconscious form of self-deception involving making excuses. In this scenario, the nurse is rationalizing her disappointment by downplaying her desire for the promotion. Denial involves ignoring the existence of a situation, which is not demonstrated here. Projection involves blaming others unconsciously, which is also not present in this situation. Compensation is an attempt to offset a perceived weakness by emphasizing a strong point, which is not shown in the nurse's response.

3. During a well-baby check of a 6-month-old infant, the nurse notes abrasions and petechiae of the palate. The nurse should:

• A. inquire about the possibility of sexual abuse.
• B. ask about the types of foods the child is eating.
• C. request to see the type of bottle used for feedings.
• D. question the parent about objects the child plays with.

Correct answer: A

Rationale: The correct answer is to inquire about the possibility of sexual abuse. Injuries to the soft palate such as bruising, abrasions, and petechiae can be signs of sexual abuse in infants. While oral sex may not leave significant physical evidence, these findings should raise suspicion. Option A is correct as it focuses on addressing potential abuse. Options B, C, and D are incorrect because the child's diet, the type of bottle used for feedings, and play objects are not likely related to the observed injuries. The presence of oral injuries suggests considering sexual abuse rather than other factors.

4. A client with schizophrenia says, 'I'm away for the day ... but don't think we should play "? or do we have feet of clay?' Which alteration in the client's speech does the nurse document?

• A. Neologism
• B. Word salad
• C. Clang association
• D. Associative looseness

Correct answer: D

Rationale: The correct answer is 'Associative looseness.' In the provided speech, the client shows associative looseness by making loose connections between phrases without a clear logical link. Clang association involves rhyming words without regard for their meaning. Neologism refers to made-up words with specific meaning to the client, and word salad is a jumble of words that lack coherence either to the listener or the client. Understanding these speech patterns associated with schizophrenia is crucial in identifying the specific alteration in speech displayed by the client in this scenario.

5. The nursing assistant hitting the client in the long-term care facility can be charged with:

• A. Negligence
• B. Tort
• C. Assault
• D. Malpractice

Correct answer: C

Rationale: Assault is the appropriate charge in this scenario. Assault involves physically striking or touching someone inappropriately. Negligence (Choice A) refers to failing to provide proper care for the client. Tort (Choice B) is a wrongful act committed against the client or their property. Malpractice (Choice D) is the failure to perform an act that should have been done or the improper performance of an act resulting in harm to the client. Since the nursing assistant physically struck the client, the charge of assault is most fitting.

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