Nursing Elites

1. A client has a history of excessive drinking, which has led to multiple arrests for driving under the influence (DUI). The client states, 'I work hard to provide for my family. I don't see why I can't drink to relax.' The nurse recognizes the use of which defense mechanism?

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

Correct answer: B

Rationale: The nurse should recognize that the client is using rationalization, a common defense mechanism. Rationalization involves creating logical reasons to justify unacceptable feelings or behaviors. In this scenario, the client is justifying excessive drinking by linking it to hard work and the need for relaxation, masking the true underlying issue of alcohol abuse. Projection involves attributing one's thoughts or feelings to others, regression involves reverting to an earlier stage of development, and sublimation involves channeling unacceptable impulses into socially acceptable activities, none of which are demonstrated in the client's statement.

2. A client diagnosed with schizophrenia is receiving discharge teaching. Which of the following instructions should the healthcare provider include? Select one that does not apply.

• A. Continue taking medications as prescribed
• B. Avoid all social interactions
• C. Report any side effects of medications to the healthcare provider
• D. Develop a daily routine

Correct answer: B

Rationale: Discharge instructions for a client diagnosed with schizophrenia should focus on promoting medication adherence, monitoring and reporting any medication side effects, and establishing a structured daily routine to support stability and well-being. Encouraging the client to avoid all social interactions is not appropriate as social support can be beneficial for individuals with schizophrenia. Social interactions can help reduce feelings of isolation, improve overall well-being, and provide emotional support. Therefore, advising the client to avoid all social interactions would not be in the best interest of their recovery and management of the condition.

3. A client is diagnosed with generalized anxiety disorder (GAD). Which of the following interventions should the nurse implement? Select one that does not apply.

• A. Encourage the client to express their feelings
• B. Teach the client relaxation techniques
• C. Promote regular physical activity
• D. Encourage the use of caffeine

Correct answer: D

Rationale: Interventions for a client with GAD should include encouraging the client to express their feelings, teaching relaxation techniques, and promoting regular physical activity. Caffeine should be avoided as it can exacerbate anxiety symptoms. Stimulants like caffeine can increase feelings of restlessness and nervousness, making it counterproductive in managing anxiety. Choices A, B, and C are appropriate interventions for managing generalized anxiety disorder by promoting emotional expression, relaxation, and physical well-being, respectively. Choice D, encouraging the use of caffeine, is incorrect as it can worsen anxiety symptoms rather than alleviate them.

4. Which patient should be most carefully assessed for fluid and electrolyte imbalance among those receiving the following drugs?

• A. lithium (Eskalith)
• B. clozapine (Clozaril)
• C. diazepam (Valium)
• D. amitriptyline

Correct answer: A

Rationale: Lithium is known to cause polyuria (excessive urination) and polydipsia (excessive thirst), which can lead to fluid and electrolyte imbalances. Therefore, patients receiving lithium should be carefully monitored for signs of fluid and electrolyte disturbances to prevent any potential complications.

5. A client diagnosed with schizophrenia is prescribed an antipsychotic medication. Which of the following side effects should the nurse monitor for? Select one that doesn't apply.

• A. Tardive dyskinesia
• B. Muscle tension
• C. Orthostatic hypotension
• D. Hyperglycemia

Correct answer: B

Rationale: Side effects of antipsychotic medications commonly include tardive dyskinesia, orthostatic hypotension, and hyperglycemia. Muscle tension is not typically associated with antipsychotic medication use. Tardive dyskinesia is characterized by involuntary movements, orthostatic hypotension refers to a drop in blood pressure upon standing, and hyperglycemia indicates high blood sugar levels. Monitoring these side effects is crucial for early detection and management, but muscle tension is not a typical side effect of antipsychotic medications.

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