Nursing Elites

1. Which of the following interventions is most appropriate when working with the family of a client who is being treated for substance abuse?

• A. Advocate for the client before the family
• B. Provide referrals for community resources and support groups
• C. Take the side of the family before the client
• D. Both B and C

Correct answer: B

Rationale: When working with the family of a client undergoing substance abuse treatment, it is crucial to support not only the client but also their family. Providing referrals for community resources and support groups is an effective intervention as it helps the family access additional support and information to cope with the challenges related to the client's substance abuse. This empowers the family to enhance their understanding of the situation and develop effective coping strategies. Advocating for the client before the family (choice A) may lead to conflicts and hinder the therapeutic process, while taking the side of the family before the client (choice C) can jeopardize the client's progress and trust. Therefore, the most appropriate intervention in this scenario is to provide referrals for community resources and support groups to ensure holistic care for both the client and their family.

2. Which defense mechanism would the nurse conclude a female client with obsessive-compulsive disorder, who washes her hands more than 20 times a day, is using to ease anxiety?

• A. Undoing
• B. Projection
• C. Introjection
• D. Displacement

Correct answer: A

Rationale: The correct answer is 'Undoing.' Undoing is a defense mechanism where the individual tries to negate a previous act to relieve guilt or anxiety. In this case, the client washing her hands excessively is trying to 'undo' perceived contamination or guilt associated with not washing. Projection (choice B) involves attributing one's own unacceptable thoughts or impulses to others, which is not demonstrated in this scenario. Introjection (choice C) is the process of internalizing beliefs or values of others, which is also not applicable in this context. Displacement (choice D) involves redirecting emotions from one target to another, which does not align with the client's behavior of handwashing as a response to anxiety in this case.

3. What factor is likely the reason a woman with bipolar disorder, manic episode, rarely eats?

• A. Feelings of guilt
• B. Need to control others
• C. Desire for punishment
• D. Excessive physical activity

Correct answer: D

Rationale: During a manic episode of bipolar disorder, individuals often experience hyperactivity and an inability to stay still. This hyperactivity can manifest as excessive physical activity, which can prevent them from eating regularly. The correct answer is 'Excessive physical activity' because it directly relates to the woman's lack of appetite during the manic episode. Feelings of guilt, the need to control others, and the desire for punishment are not typically associated with eating difficulties in individuals with bipolar disorder during a manic episode. Clients in a manic episode usually have heightened energy levels and may engage in activities that exhaust them, leading to a decreased focus on eating.

4. Which clinical findings indicate positive signs and symptoms of schizophrenia?

• A. Withdrawal, poverty of speech, inattentiveness
• B. Flat affect, decreased spontaneity, asocial behavior
• C. Hypomania, labile mood swings, episodes of euphoria
• D. Bizarre behavior, auditory hallucinations, loose associations

Correct answer: D

Rationale: The correct answer is bizarre behavior, auditory hallucinations, and loose associations. These are positive symptoms of schizophrenia, reflecting a distortion or excess of normal function. Withdrawal, poverty of speech, inattentiveness, flat affect, decreased spontaneity, and asocial behavior are negative symptoms linked to schizophrenia, indicating a diminution or absence of normal function. Hypomania, labile mood swings, and episodes of euphoria are more characteristic of bipolar disorder, rather than schizophrenia.

5. The nurse who is preparing to give an adolescent client a prescribed antipsychotic medication notes that parental consent has not been obtained. Which action should the nurse take?

• A. Review the chart for a signed consent for medication administration.
• B. Get the guardian's permission to give the medication.
• C. Do not give the medication and document the reason.
• D. Complete an incident report and notify the supervisor.

Correct answer: C

Rationale: In this scenario, the correct action for the nurse to take is not to administer the medication and document the reason. Since the adolescent client is a minor, parental or guardian consent is required for medical treatment, including medication administration. Option A, reviewing the chart for a signed consent for medication administration, is not the appropriate action in this situation as the focus is on parental consent for the client. Option B is incorrect because obtaining the health care provider's permission does not replace the need for parental consent for a minor. Option D, completing an incident report and notifying the supervisor, is unnecessary as there is no adverse event to report; the key concern is the lack of parental consent for medication administration.

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