Nursing Elites

1. A young adult male who is being seen at the employee health care clinic for an annual assessment tells the nurse that his mother was diagnosed with schizophrenia when she was his age and that life with a schizophrenic mother was difficult indeed. Which response is best for the nurse to provide?

• A. Ask the client if he is worried about becoming schizophrenic at the age his mother was diagnosed.
• B. Encourage the client to seek genetic counseling to determine his risk for mental illness.
• C. Inform the client that his mother’s schizophrenia has affected his psychological development.
• D. Tell the client that mental illness has a familial predisposition so he should see a psychiatrist.

Correct answer: B

Rationale: Genetic counseling can help assess risk and provide guidance for the client’s concerns about potential hereditary conditions.

2. The mother of a teenager is told that her son has recently been found stealing from other students at school. The mother's response is, 'I cannot think about that today.' The nurse determines that this mother is using which defense mechanism?

• A. Suppression
• B. Repression
• C. Sublimation
• D. Undoing

Correct answer: A

Rationale: The correct answer is A, Suppression. Suppression involves a conscious effort to avoid dealing with distressing thoughts or feelings. In this case, the mother is consciously choosing not to think about her son's behavior. Choice B, Repression, involves unconsciously blocking out distressing thoughts or feelings. Choice C, Sublimation, is the channeling of unacceptable impulses into socially acceptable behaviors, which is not demonstrated in this scenario. Choice D, Undoing, is a defense mechanism where a person tries to undo or reverse a negative thought or action by performing a contrary behavior, which is not applicable here.

3. After learning that she has terminal pancreatic cancer, a female client becomes very angry and says to the nurse, 'God has abandoned me. What did I do to deserve this?' Based on this response, the nurse decides to include which nursing problem in the client’s plan of care?

• A. Ineffective coping
• B. Spiritual distress
• C. Acute pain
• D. Complicated grieving

Correct answer: B

Rationale: The client’s expression of feeling abandoned by God indicates spiritual distress, which is a significant issue that needs to be addressed in the plan of care. The individual is questioning their faith and seeking answers in a higher power, which aligns with spiritual distress. Choices A, C, and D are not as directly related to the client's current emotional and spiritual struggle. Ineffective coping may be a consequence of spiritual distress, acute pain is not the primary concern in this scenario, and complicated grieving is premature as the client is still processing the diagnosis and seeking meaning.

4. The client is assessing a client who was recently diagnosed with heart failure and is on a low-sodium diet. Which statement by the client indicates a need for further teaching?

• A. “I will use lemon juice and herbs for flavoring.”
• B. “I will not eat canned soups or frozen dinners.”
• C. “I can have salt substitutes to enhance the taste of my food.”
• D. “I will check the food labels for sodium content before buying.”

Correct answer: C

Rationale: The correct answer is C. Some salt substitutes can be high in potassium, which may not be suitable for clients with heart failure. Option A is correct as using lemon juice and herbs for flavoring is a good low-sodium alternative. Option B is also correct as canned soups and frozen dinners are typically high in sodium content. Option D is correct as checking food labels for sodium content is an essential part of managing a low-sodium diet. Therefore, the client's statement about using salt substitutes needs correction as it can introduce high levels of potassium, which may not be recommended for individuals with heart failure.

5. What nursing intervention is most important to implement after a client has completed a myelogram?

• A. Lie-sit-stand blood pressure measurement
• B. Abdominal assessment for distention and bowel sounds
• C. Neurovascular assessment of lower extremities
• D. Assessment of skin temperature and turgor

Correct answer: C

Rationale: The correct answer is C: Neurovascular assessment of the lower extremities. After a myelogram, it is crucial to monitor the neurovascular status to detect any signs of complications such as impaired circulation or nerve damage. This assessment helps in identifying early signs of vascular compromise or neurological deficits. Choices A, B, and D are not the priority after a myelogram. Lie-sit-stand blood pressure measurement is not directly related to post-myelogram care. Abdominal assessment and skin assessment are important but not the priority immediately after this procedure.

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