Nursing Elites

1. In what significant way should the therapeutic environment differ for a client who has ingested LSD from that of a client who has ingested PCP?

• A. For LSD ingestion, maintain a regimen of limited interaction and minimal verbal stimulation. For PCP ingestion, place client on one-on-one intensive supervision.
• B. For LSD ingestion, place the client in restraints. For PCP ingestion, place the client on seizure precautions.
• C. For LSD ingestion, provide continual medieval simulation involving as many senses as possible. For PCP ingestion, provide continual high-level stimulation.
• D. For PCP ingestion, place the client on one-on-one intensive supervision. For LSD ingestion, maintain a regimen of limited interaction and minimal verbal stimulation.

Correct answer: D

Rationale: When managing a client who has ingested PCP, it is crucial to provide one-on-one intensive supervision to ensure their safety and prevent any harm to themselves or others. This level of supervision is necessary due to the unpredictable and potentially dangerous effects of PCP. On the other hand, for a client who has ingested LSD, it is recommended to maintain a calm environment with limited interaction and minimal verbal stimulation. This approach aims to prevent exacerbating any adverse effects of LSD, such as anxiety or paranoia, by reducing external stimuli. Therefore, the correct approach is to provide one-on-one intensive supervision for PCP ingestion and limit interaction and verbal stimulation for LSD ingestion.

2. A healthcare professional is assessing a client who has been diagnosed with major depressive disorder. Which symptom should the healthcare professional expect to observe?

• A. Increased energy
• B. Weight gain
• C. Increased appetite
• D. Restlessness

Correct answer: B

Rationale: Weight gain is a common symptom of major depressive disorder. Individuals with major depressive disorder often experience changes in appetite, leading to weight gain or loss. This symptom is related to disruptions in the individual's eating habits and metabolism, which are commonly associated with depression. Choices A, C, and D are incorrect because increased energy, increased appetite, and restlessness are not typical symptoms of major depressive disorder. In fact, individuals with depression often experience fatigue, changes in appetite, and feelings of restlessness or agitation.

3. You have been working closely with a patient for the past month. Today he tells you he is looking forward to meeting with his new psychiatrist but frowns and avoids eye contact while reporting this to you. Which of the following responses would most likely be therapeutic?

• A. A new psychiatrist is a chance to start fresh; I'm sure it will go well for you.
• B. You say you look forward to the meeting, but you appear anxious or unhappy.
• C. I notice that you frowned and avoided eye contact just now. Don't you feel well?
• D. I get the impression you don't really want to see your psychiatrist—can you tell me why?

Correct answer: B

Rationale: Choice B is the most therapeutic response as it acknowledges the discrepancy between the patient's verbal statement and nonverbal cues. By addressing both the patient's expressed anticipation and the conflicting nonverbal cues of frowning and avoiding eye contact, the responder demonstrates attentiveness to the patient's emotional state and encourages further exploration of underlying feelings. This approach fosters open communication and helps the patient feel understood and supported.

4. A patient with schizophrenia is experiencing hallucinations. Which intervention is most appropriate?

• A. Encourage the patient to ignore the voices.
• B. Engage the patient in a reality-based activity.
• C. Provide a quiet environment to reduce stimulation.
• D. Ask the patient to describe the hallucinations in detail.

Correct answer: B

Rationale: Engaging the patient in a reality-based activity is the most appropriate intervention for a patient with schizophrenia experiencing hallucinations. This intervention can help distract the patient from the hallucinations and reorient them to the present, promoting a connection with reality and potentially reducing distress associated with the hallucinations. Choice A, encouraging the patient to ignore the voices, may not be effective as it can be challenging for the patient to dismiss the hallucinations. Choice C, providing a quiet environment, is helpful but may not directly address the hallucinations. Choice D, asking the patient to describe the hallucinations in detail, may increase the patient's focus on the hallucinations, potentially worsening distress.

5. A teenage boy is attracted to a female teacher. Without objective evidence, a school nurse overhears the boy state, 'I know she wants me.' This statement reflects which defense mechanism?

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

Correct answer: B

Rationale: The correct answer is B: Projection. The nurse should determine that the client's statement reflects the defense mechanism of projection. Projection involves attributing one's unacceptable feelings or impulses to another person. By projecting these feelings onto someone else, the individual reduces their own anxiety. Displacement involves transferring feelings from one target to another, not attributing them to another person. Rationalization involves making excuses to justify behavior, not attributing feelings to others. Sublimation involves channeling unacceptable drives or impulses into more constructive and acceptable activities, not attributing feelings to another person.

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