Nursing Elites

1. A client recently had an abdominoperineal resection and colostomy. While the nurse changes the dressing, the client states, 'You think that it looks repulsive.' The nurse identifies that the client is using which defense mechanism?

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

Correct answer: A

Rationale: The correct answer is Projection. Projection is the defense mechanism where unacceptable feelings and emotions are attributed to others. In this scenario, the client is projecting their own feelings of repulsion onto the nurse. Sublimation involves substituting socially acceptable feelings to replace threatening ones. Compensation refers to overachievement in a different area to cover up a weakness. Intellectualization is the use of mental reasoning to avoid facing emotional aspects of a situation.

2. An adolescent reports irregularity in menses. Her mother complains that her child often fears gaining weight, has poor caloric intake, and has a distorted self-image. Which could be the reason for irregular menses?

• A. Bulimia
• B. Anorexia
• C. Orthorexia
• D. Binge eating disorder

Correct answer: B

Rationale: The correct answer is 'Anorexia.' Anorexia is characterized by a lack of caloric intake motivated by a strong fear of gaining weight, leading to poor nutrition and potential irregular menses. Bulimia involves binge eating followed by compensatory behaviors. Orthorexia is characterized by an obsession with eating only healthy or 'pure' foods. Binge eating disorder is characterized by consuming large amounts of high-calorie food in a short period.

3. The nurse selects the best site for insertion of an IV catheter in the client's right arm. Which documentation should the nurse use to identify the placement of the IV access?

• A. Left brachial vein
• B. Right cephalic vein
• C. Dorsal side of the right wrist
• D. Right upper extremity

Correct answer: B

Rationale: The correct answer is the right cephalic vein. The cephalic vein is a large and superficial vein commonly used for IV access. Documenting the specific anatomic name of the vein used for IV access, such as the cephalic vein, is essential for accurate medical records. Option A, the left brachial vein, is incorrect as the brachial vein is too deep to be accessed for IV infusion. Option C, the dorsal side of the right wrist, is not a recommended IV access site due to fragile veins and potential pain for the patient. Option D, right upper extremity, is too broad and lacks the specificity necessary for precise documentation of the IV access site.

4. Under what patient conditions or situations are restraints sometimes used?

• A. As punishment when the patient is uncontrollable
• B. To prevent the patient from pulling their IV out
• C. When a patient is a danger to self and others
• D. Both B and C

Correct answer: D

Rationale: Restraints are sometimes used to prevent a patient from pulling out their IV or another life-saving tube and when the person poses a serious danger to themselves and/or others. Restraints are never used as a form of punishment. Choice A is incorrect because restraints are not utilized for punishment but for patient safety and care. Choice B and C are correct because they reflect the appropriate and necessary situations where restraints may be used in healthcare settings.

5. While explaining an illness to a 10-year-old, what should the nurse keep in mind about cognitive development at this age?

• A. They are able to make simple associations of ideas.
• B. They are able to think logically in organizing facts.
• C. Interpretation of events originates from their own perspective.
• D. Conclusions are based on previous experiences.

Correct answer: B

Rationale: The correct answer is that 10-year-olds are able to think logically in organizing facts. At this age, children are in the concrete operational stage according to Piaget's theory of cognitive development. In this stage, they can understand and organize information logically and can manipulate objects mentally. Choice A is incorrect because simple associations of ideas are more characteristic of earlier developmental stages. Choice C is incorrect as it refers to egocentrism, which is more typical of the preoperational stage. Choice D is incorrect as basing conclusions on previous experiences is a broader concept that applies across different ages and stages of development, rather than being specific to 10-year-olds in the concrete operational stage.

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