Nursing Elites

1. A client is experiencing alcohol withdrawal. Which intervention should be included in the plan of care?

• A. Administer benzodiazepines as prescribed.
• B. Monitor the client's vital signs every 4 hours.
• C. Provide a high-protein diet.
• D. Encourage the client to drink plenty of fluids.

Correct answer: A

Rationale: Administering benzodiazepines as prescribed is a crucial intervention in managing alcohol withdrawal. Benzodiazepines help alleviate symptoms such as anxiety, agitation, and seizures commonly seen in alcohol withdrawal. Monitoring vital signs is important to assess the client's physiological stability, but addressing the withdrawal symptoms with benzodiazepines is a priority to prevent severe complications. Providing a high-protein diet and encouraging fluid intake are important for overall health but do not directly manage alcohol withdrawal symptoms.

2. A 10-year-old boy breaks his mother's vase while playing. When the mother asks who broke the vase, the little boy says that his sister did it. The little boy is exhibiting which defense mechanism?

• A. Projection
• B. Displacement
• C. Dissociation
• D. Sublimation

Correct answer: A

Rationale: Projection is a defense mechanism where one attributes their own unacceptable thoughts, feelings, or impulses onto another person. In this scenario, the little boy is projecting his actions onto his sister by falsely claiming she broke the vase. Displacement involves transferring emotions from the original source to a substitute target. Dissociation is a disconnection between thoughts, identity, consciousness, and memory. Sublimation is the redirection of unacceptable impulses into socially acceptable activities.

3. Which therapeutic communication statement might a psychiatric-mental health registered nurse use when a patient's nursing diagnosis is altered thought processes?

• A. I know you say you hear voices, but I cannot hear them.
• B. Stop listening to the voices, they are NOT real.
• C. You say you hear voices, what are they telling you?
• D. Please tell the voices to leave you alone for now.

Correct answer: C

Rationale: Asking about the content of the voices helps understand the patient's experience and assess risk.

4. A healthcare provider is providing care for a patient with schizophrenia. Which symptom would be considered a positive symptom of this disorder?

• A. Alogia
• B. Anhedonia
• C. Delusions
• D. Flat affect

Correct answer: C

Rationale: Delusions are considered a positive symptom of schizophrenia. Positive symptoms represent an excess or distortion of normal functions, such as hallucinations, delusions, or disorganized speech or behavior. In contrast, negative symptoms involve a decrease or absence of normal functions, like alogia (poverty of speech), anhedonia (inability to experience pleasure), and flat affect (reduced expression of emotions). Therefore, in the context of schizophrenia, delusions fall under the category of positive symptoms.

5. Which of the following is a common side effect of antipsychotic medications?

• A. Hyperactivity
• B. Weight loss
• C. Extrapyramidal symptoms
• D. Insomnia

Correct answer: C

Rationale: Extrapyramidal symptoms, such as tremors and rigidity, are frequently observed as side effects of antipsychotic medications. These symptoms result from the medications' influence on dopamine receptors in the brain. Choice A, hyperactivity, is not a typical side effect of antipsychotic medications. Choice B, weight loss, is less common compared to weight gain. Choice D, insomnia, though possible, is not as prevalent as extrapyramidal symptoms in individuals taking antipsychotic medications.

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