Nursing Elites

1. Which client statement suggests that the client is using a defense mechanism of projection to deal with anxiety related to admission to a psychiatric unit?

• A. At least I hit the wall instead of hitting the psychiatric aide.
• B. I am here because the police thought I was doing something wrong.
• C. I want to be here because I know it is the best psychiatric facility.
• D. Don’t believe everything my family tells you, I am not crazy.

Correct answer: A

Rationale: The correct answer is A because the client is projecting their own aggressive tendencies onto the psychiatric aide by suggesting hitting the wall instead of the aide. This statement reflects projection, a defense mechanism where one attributes their unacceptable feelings or impulses to others. Choice B reflects externalization rather than projection, Choice C reflects rationalization, and Choice D reflects denial.

2. Which factors tend to increase the difficulty of diagnosing young children who demonstrate behaviors associated with mental illness? Select all that apply.

• A. Limited language skills
• B. Level of cognitive development
• C. Level of emotional development
• D. Parental denial that a problem exists

Correct answer: B

Rationale: The correct answer is B: Level of cognitive development. The level of cognitive development is a crucial factor that can complicate the diagnosis of mental illness in young children. Young children may not have fully developed cognitive abilities to express their symptoms or understand diagnostic procedures, making it challenging for healthcare providers to assess their mental health accurately. Limited language skills (choice A) can hinder communication but are not as significant as cognitive development in diagnosing mental illness. Emotional development (choice C) is important but may not be as directly linked to the diagnostic challenges as cognitive development. Parental denial (choice D), although a potential barrier, is not a factor inherent to the child's characteristics affecting the diagnostic process.

3. A client tells the RN that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. What is the priority nursing problem for admission to the psychiatric unit?

• A. Ineffective sexual patterns.
• B. Impaired environmental interpretation.
• C. Disturbed sensory perception.
• D. Compromised family coping.

Correct answer: C

Rationale: The priority nursing problem for admission to the psychiatric unit is 'Disturbed sensory perception.' This choice is correct because the client's delusional beliefs about having an IQ of 400+, being a genius and an inventor, being married to a movie star, and suspecting his brother of wanting a sexual relationship with her indicate a significant disturbance in sensory perception. The client's perceptions are not based in reality, indicating a need for immediate intervention to address these distorted beliefs. Choices A, B, and D are incorrect: 'Ineffective sexual patterns' is not the priority as the client's delusions go beyond just sexual relationships, 'Impaired environmental interpretation' does not capture the primary issue of distorted perceptions, and 'Compromised family coping' is not the priority concern in this scenario compared to the severe sensory perception disturbances displayed by the client.

4. A healthcare provider is evaluating a client's response to a new antianxiety medication. Which client statement indicates a positive response to the medication?

• A. “I feel more relaxed and less anxious.”
• B. “I am sleeping less and feel more energetic.”
• C. “I have not noticed any changes in my anxiety levels.”
• D. “I have more difficulty concentrating than before.”

Correct answer: A

Rationale: The correct answer is A: “I feel more relaxed and less anxious.” A positive response to antianxiety medication is characterized by reduced anxiety and increased relaxation. Choice B, which mentions sleeping less and feeling more energetic, suggests potential side effects rather than a positive response to the medication. Choice C indicates no change in anxiety levels, which is not indicative of a positive response. Choice D, mentioning difficulty concentrating, is also a sign of a negative response to antianxiety medication as it may suggest cognitive impairment.

5. A client with depression remains in bed most of the day and declines activities. Which nursing problem has the greatest priority for this client?

• A. Loss of interest in diversional activity.
• B. Social isolation.
• C. Refusal to address nutritional needs.
• D. Low self-esteem.

Correct answer: C

Rationale: The correct answer is C: 'Refusal to address nutritional needs.' When a client with depression remains in bed and declines activities, addressing their refusal to address nutritional needs is of utmost priority. Nutritional needs are essential for physical health and overall well-being. Inadequate nutrition can worsen the client's physical health, impact their mood, and hinder the effectiveness of treatment. Option A, 'Loss of interest in diversional activity,' while important, is not as critical as addressing nutritional needs for immediate physical well-being. Option B, 'Social isolation,' is a significant concern but addressing nutritional needs takes precedence due to its direct impact on physical health. Option D, 'Low self-esteem,' is a valid concern but does not take priority over addressing the client's refusal to meet their nutritional needs for immediate health benefits.

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