Nursing Elites

1. While assessing a distraught female high school student who is overly concerned because her parents can't afford horseback riding lessons, how should the nurse interpret the student's reaction to her perceived problem?

• A. The problem is endangering her well-being.
• B. The problem is personally relevant to her.
• C. The problem is based on immaturity.
• D. The problem is exceeding her capacity to cope.

Correct answer: B

Rationale: In this scenario, the student being overly concerned about not being able to afford horseback riding lessons indicates that the problem is personally relevant to her. Psychological stressors related to self-esteem and self-image are influenced by how an individual perceives a situation or event. Adolescents, in particular, place significance on self-image and feeling entitled to experiences that other adolescents have, which can lead to distress when such desires are not met. Choice A is incorrect because there is no indication that the student's physical well-being is at risk. Choice C is incorrect as it simplifies the issue by attributing it solely to immaturity. Choice D is incorrect as there is no evidence provided that the problem is beyond the student's coping abilities.

2. A client has been prescribed bupropion (Wellbutrin) for depression. Which instruction should the nurse provide during discharge?

• A. Take the medication with a full glass of water.
• B. Stop taking the medication if you feel better.
• C. Avoid drinking alcohol while taking this medication.
• D. Double the dose if you miss a dose.

Correct answer: C

Rationale: The correct instruction for the nurse to provide is to advise the client to avoid drinking alcohol while taking bupropion (Wellbutrin) due to the increased risk of side effects like seizures. Alcohol can interact with bupropion and worsen its side effects, making it important to abstain from alcohol consumption during the treatment. Option A is incorrect because taking the medication with a full glass of water is a general instruction for medications and not specific to bupropion. Option B is incorrect as abruptly stopping bupropion can lead to withdrawal symptoms and should only be done under medical supervision. Option D is incorrect as doubling the dose of bupropion is dangerous and should not be done, even if a dose is missed.

3. 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.

4. Kyle, a patient with schizophrenia, began taking the first-generation antipsychotic haloperidol (Haldol) last week. One day you find him sitting very stiffly and not moving. He is diaphoretic, and when you ask if he is okay, he seems unable to respond verbally. His vital signs are: BP 170/100, P 110, T 104.2°F. What is the priority nursing intervention? Select one that does not apply.

• A. Hold his medication and contact his prescriber.
• B. Wipe him with a washcloth wet with cold water or alcohol.
• C. Administer a medication such as benztropine IM to correct this dystonic reaction.
• D. Reassure him that although there is no treatment for his tardive dyskinesia, it will pass.

Correct answer: C

Rationale: The patient's symptoms, including stiffness, diaphoresis, inability to respond verbally, and vital sign abnormalities, are indicative of neuroleptic malignant syndrome (NMS), a serious and potentially life-threatening side effect of antipsychotic medications. Administering a medication such as benztropine intramuscularly is the priority to address the dystonic reaction associated with NMS. This intervention can help alleviate symptoms and prevent further complications. Holding the medication and contacting the prescriber may be necessary but addressing the acute symptoms takes precedence. Wiping the patient with a cold washcloth or alcohol would not address the underlying medical emergency. Reassuring the patient about tardive dyskinesia is irrelevant and not the immediate concern in this scenario.

5. A client has been diagnosed with borderline personality disorder. Which behavior is characteristic of this disorder?

• A. Excessive need for attention
• B. Instability in relationships
• C. Fear of abandonment
• D. Lack of interest in activities

Correct answer: B

Rationale: The correct answer is B: Instability in relationships. Individuals with borderline personality disorder often exhibit instability in their relationships, characterized by intense and unstable interpersonal connections, oscillating between idealization and devaluation. This pattern can lead to frequent conflicts, dramatic emotional shifts, and difficulties maintaining stable relationships. Choices A, C, and D are incorrect. While individuals with borderline personality disorder may also have an excessive need for attention, fear of abandonment, or lack of interest in activities, the hallmark feature defining this disorder is the instability in relationships.

Similar Questions