Nursing Elites

1. What assessment questions should the nurse ask when attempting to determine a teenager’s mental health resilience? Select all that apply.

• A. How did you cope when your father deployed with the Army for a year in Iraq?
• B. Who did you go to for advice while your father was away for a year in Iraq?
• C. How do you feel about talking to a mental health counselor?
• D. Where do you see yourself in 10 years?

Correct answer: C

Rationale: The question 'How do you feel about talking to a mental health counselor?' is the most appropriate to assess the teenager's mental health resilience as it directly addresses their willingness to seek help and cope effectively. Choices A and B focus on coping mechanisms during a specific event, which may not reflect the teenager's overall resilience. Choice D is more related to future aspirations rather than assessing current mental health resilience.

2. A client who has a history of bipolar disorder is recovering from a manic episode and is now experiencing depressive symptoms. Which action should the nurse take first?

• A. Assess the client for suicidal ideation.
• B. Provide a detailed schedule of daily activities.
• C. Discuss the importance of medication adherence.
• D. Encourage the client to engage in group therapy.

Correct answer: A

Rationale: Assessing for suicidal ideation is the priority when a client with bipolar disorder is transitioning from a manic episode to a depressive phase. Suicidal ideation is a critical concern during depressive episodes, and ensuring the client's safety is the top priority. Providing a detailed schedule of daily activities (Choice B) may be helpful but is not the immediate priority over assessing for suicidal ideation. Discussing the importance of medication adherence (Choice C) and encouraging group therapy (Choice D) are essential components of care but are secondary to ensuring the client's safety in the context of potential suicidal ideation.

3. A male client with bipolar disorder who began taking lithium carbonate five days ago is complaining of excessive thirst, and the RN finds him attempting to drink water from the bathroom sink faucet. Which intervention should the RN implement?

• A. Report the client’s serum lithium level to the healthcare provider (HCP).
• B. Encourage the client to suck on hard candy to relieve the symptoms.
• C. No action is needed since polydipsia is a common side effect.
• D. Tell the client that drinking from the faucet is not allowed.

Correct answer: B

Rationale: Encouraging the client to suck on hard candy is the appropriate intervention in this situation. Excessive thirst is a common side effect of lithium therapy. Sucking on hard candy can help alleviate the symptom without posing any harm. Reporting the client's serum lithium level to the healthcare provider (Choice A) is not necessary at this point as the symptom of excessive thirst is a known side effect and does not indicate toxicity. No action is needed (Choice C) is incorrect because addressing the client's distress is essential. Telling the client that drinking from the faucet is not allowed (Choice D) does not address the underlying issue of excessive thirst and may cause further distress to the client.

4. A healthcare provider is evaluating a client's response to a new antianxiety medication. Which client statement indicates a positive response to the medication?

• A. “I feel more relaxed and less anxious.”
• B. “I am sleeping less and feel more energetic.”
• C. “I have not noticed any changes in my anxiety levels.”
• D. “I have more difficulty concentrating than before.”

Correct answer: A

Rationale: The correct answer is A: “I feel more relaxed and less anxious.” A positive response to antianxiety medication is characterized by reduced anxiety and increased relaxation. Choice B, which mentions sleeping less and feeling more energetic, suggests potential side effects rather than a positive response to the medication. Choice C indicates no change in anxiety levels, which is not indicative of a positive response. Choice D, mentioning difficulty concentrating, is also a sign of a negative response to antianxiety medication as it may suggest cognitive impairment.

5. A male client approaches the RN with an angry expression on his face and raises his voice, saying, “My roommate is the most selfish, self-centered, angry person I have ever met. If he loses his temper one more time with me, I am going to punch him out!” The RN recognizes that the client is using which defense mechanism?

• A. Denial.
• B. Projection.
• C. Rationalization.
• D. Splitting.

Correct answer: B

Rationale: The correct answer is B: Projection. Projection involves attributing one's own unacceptable feelings or thoughts to others, as seen in the client’s accusations of his roommate’s behavior. In this scenario, the client is projecting his own anger and potential for violence onto his roommate. Choice A, Denial, involves refusing to acknowledge some aspect of reality, which is not evident in the scenario. Choice C, Rationalization, is a defense mechanism where logical reasons are given to justify behaviors that are actually based on unacceptable motives, which is not demonstrated by the client's behavior. Choice D, Splitting, is a defense mechanism where a person sees others as all good or all bad, not applicable in this case as the client is not portraying extreme views of his roommate.

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