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. When observing an infant lying quietly in the bassinet with eyes open wide, what action should the nurse take in response to the infant's behavior?

• A. Brightening the lights in the room
• B. Encouraging the mother to talk to her baby
• C. Wrapping and then turning the infant to the side
• D. Beginning physical and behavioral assessments

Correct answer: B

Rationale: When an infant is lying quietly in a bassinet with eyes open wide, it indicates a quiet, alert state. This state is optimal for infant stimulation and interaction. Bright lights can be disturbing to newborns and may disrupt the mother-infant interaction. Wrapping and turning the infant to the side is typically done for a sleeping infant. While physical and behavioral assessments are important, in this scenario, the priority is to encourage mother-infant bonding and communication, as it is a valuable opportunity for interaction and stimulation.

3. The mother of an infant in the neonatal intensive care unit expresses concern about her infant. Which nursing intervention best facilitates mother-infant bonding?

• A. Asking the mother to change her baby's diaper
• B. Assuring the mother that her baby is receiving excellent care
• C. Encouraging the mother to touch her baby whenever possible
• D. Keeping the mother informed about the care the nursing staff is providing her baby

Correct answer: C

Rationale: Encouraging the mother to touch her baby whenever possible is the best intervention to promote mother-infant bonding, especially when the infant is too ill to be held. Physical touch is a powerful way to establish a connection. Mother-infant bonding is a gradual process and encouraging touch can help initiate this bond. Asking the mother to change her baby's diaper is not the most appropriate action to promote bonding in this scenario. Assuring the mother about the care her baby is receiving is important but does not directly enhance bonding. Keeping the mother informed about the care her baby is receiving is crucial, but it alone does not actively foster bonding between the mother and infant.

4. A client at a local university claims to be the president of the university. Which type of delusion is the client displaying?

• A. Somatic
• B. Grandiose
• C. Erotomanic
• D. Persecutory

Correct answer: B

Rationale: The correct answer is 'Grandiose.' This type of delusion involves an exaggerated sense of self-importance, where the individual believes they are a prominent figure or possess special abilities. In this scenario, the client claiming to be the president of the university is displaying grandiose delusions. Somatic delusions relate to bodily functions or sensations, which are not present in this case. Erotomanic delusions involve the fixed belief that another person is in love with the individual, which is not applicable here. Persecutory delusions involve the belief that one is being targeted or conspired against, which is also not demonstrated in the given situation.

5. A client with invasive carcinoma of the bladder is scheduled for a cystectomy and an ileal conduit. The client expresses worries about the possibility of offensive odors associated with the urinary diversion. How would the nurse respond?

• A. ''Tell me more about your concerns.''
• B. ''Products are available to address this issue.''
• C. ''This is a valid concern, and we can discuss ways to manage it.''
• D. ''Many individuals who undergo this procedure have similar worries.''

Correct answer: A

Rationale: The response ''Tell me more about your concerns'' is open-ended, encouraging the client to express their worries freely. This approach fosters communication and shows empathy. Option B acknowledges the concern and offers a solution, demonstrating support and understanding. Option C validates the client's worry and suggests collaboration in finding solutions. Option D normalizes the concern but may not address the client's specific worries, making it less therapeutic than the other options. Overall, actively listening to the client's concerns and offering support are essential in providing holistic care.

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