Nursing Elites

1. A client says, 'I hear a man speaking from the corner of the room. Do you hear him, too?' Which response is best?

• A. What is he saying to you? Does it make any sense?
• B. Yes, I hear him. What do you think he is saying?
• C. No one is in the corner of the room. Can't you see that?
• D. No, I don't hear him, but that must be upsetting for you.

Correct answer: D

Rationale: The best response is D: 'No, I don't hear him, but that must be upsetting for you.' This response acknowledges the client's experience without validating the hallucination. The nurse expresses empathy by acknowledging the client's feelings ('that must be upsetting for you'), showing understanding and support. Choice A focuses on the content of the hallucination, which may inadvertently reinforce the delusion. Choice B validates the hallucination by agreeing that the nurse also hears the man. Choice C denies the client's experience and can lead to further distress by invalidating their perception.

2. Which defense mechanism is considered a conscious measure used to cope with anxiety?

• A. Undoing
• B. Projection
• C. Suppression
• D. Intellectualization

Correct answer: C

Rationale: The correct answer is Suppression. Suppression is a conscious defense mechanism in which an individual intentionally avoids thinking about disturbing problems, wishes, feelings, or experiences. It is a way to cope with anxiety by actively pushing aside unwanted thoughts or emotions. Undoing, on the other hand, is an unconscious defense mechanism where one uses words or behaviors to symbolically make amends for unacceptable thoughts or actions. Projection is also an unconscious defense mechanism involving falsely attributing one's own unacceptable impulses to others. Intellectualization, another unconscious defense mechanism, involves using intellect or thinking to avoid dealing with emotionally charged feelings.

3. Which response would the nurse make to a client who says, 'The voices say I'll be safe only if I stay in this room, wear these clothes, and avoid stepping on the cracks between the floor tiles'?

• A. Ask whether the voices are male or female and how many there are.
• B. Reassure the client by stating, 'I understand that these voices are real to you, but I want you to know that I don't hear them.'
• C. Offer false reassurance by saying, 'Don't worry"?I've locked the door to your room and won't let anyone in.'
• D. Encourage the client to leave the room and keep busy to distract from the voices.

Correct answer: B

Rationale: The response, 'I understand that these voices are real to you, but I want you to know that I don't hear them,' demonstrates empathy and validation of the client's experience while also gently bringing in the nurse's reality. This response acknowledges the client's feelings without reinforcing the hallucinations. Asking about the characteristics of the voices (Choice A) can inadvertently validate the hallucinations. Offering false reassurance (Choice B) may not be helpful as it does not address the client's distress. Encouraging the client to leave the room and keep busy (Choice D) is nontherapeutic as it disregards the client's experience and may increase anxiety.

4. For a client with obsessive-compulsive disorder, which reaction is most likely to occur when the performance of a ritual is interrupted?

• A. Anxiety
• B. Hostility
• C. Aggression
• D. Withdrawal

Correct answer: A

Rationale: When a client with obsessive-compulsive disorder is interrupted while performing a ritual, the most likely reaction is anxiety. The compulsive ritual serves as a coping mechanism to control anxiety, so any disruption to this ritual can heighten the individual's anxiety levels. Hostility is typically part of the disorder itself and not a direct reaction to the interruption of the ritual. Aggression may occur only if anxiety escalates to a panic level, leading to overt anger expression. Withdrawal is not a common behavioral pattern associated with obsessive-compulsive disorder and is not a typical reaction to ritual interruption.

5. Which characteristic would be a concern for the nurse when caring for a client with schizophrenia in the early phase of treatment?

• A. Continual pacing
• B. Suspicious feelings
• C. Inability to socialize with others
• D. Disturbed relationship with the family

Correct answer: B

Rationale: In the early phase of treatment for a client with schizophrenia, the nurse needs to address the client's suspicious feelings to establish trust and create a therapeutic environment. Suspicious feelings can hinder the development of a positive nurse-client relationship. Continual pacing, while a symptom, can be managed by the nurse and does not directly impact the therapeutic relationship. Inability to socialize with others and a disturbed relationship with the family are important factors but are of lesser concern in the early treatment phase as compared to addressing suspicious feelings to build trust and rapport.

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