Nursing Elites

1. Which defense mechanism is considered a conscious measure used to cope with anxiety?

• A. Undoing
• B. Projection
• C. Suppression
• D. Intellectualization

Correct answer: C

Rationale: The correct answer is Suppression. Suppression is a conscious defense mechanism in which an individual intentionally avoids thinking about disturbing problems, wishes, feelings, or experiences. It is a way to cope with anxiety by actively pushing aside unwanted thoughts or emotions. Undoing, on the other hand, is an unconscious defense mechanism where one uses words or behaviors to symbolically make amends for unacceptable thoughts or actions. Projection is also an unconscious defense mechanism involving falsely attributing one's own unacceptable impulses to others. Intellectualization, another unconscious defense mechanism, involves using intellect or thinking to avoid dealing with emotionally charged feelings.

2. Which thought process would the nurse document the mental health client is experiencing after the client says, 'The FBI is out to kill me'?

• A. Hallucinations
• B. Error in judgment
• C. Delusion of persecution
• D. Self-accusatory delusion

Correct answer: C

Rationale: The nurse would document that the client is experiencing a delusion of persecution. A delusion of persecution is a fixed and firm belief of being harassed, in danger, or at the mercy of others, as illustrated by 'The FBI is out to kill me.' Hallucinations are perceived experiences that occur without actual sensory stimulation. Error in judgment refers to poor decision-making, not a distortion of reality like a delusion. A self-accusatory delusion involves accepting blame for an act that was never committed or a feeling that was never acted on. Therefore, the correct choice is 'Delusion of persecution.'

3. Which serum laboratory value should the nurse monitor carefully for a client who has a nasogastric (NG) tube to suction for the past week?

• A. White blood cell count
• B. Albumin
• C. Calcium
• D. Sodium

Correct answer: D

Rationale: The nurse should monitor the client's serum sodium levels carefully when they have been on nasogastric (NG) tube suction for an extended period. Prolonged NG suctioning can lead to fluid loss and subsequent hyponatremia. Monitoring sodium levels is crucial to prevent complications. White blood cell count (Option A), albumin (Option B), and calcium (Option C) are not typically affected by prolonged NG suctioning. Therefore, these values are not the priority for monitoring in this situation.

4. When developing Jerry's plan of care, which of the following would NOT be helpful to include?

• A. Limiting choices
• B. Providing structure
• C. Encouraging patient input
• D. Ensuring availability of PRN medications

Correct answer: A

Rationale: Limiting choices would not be helpful in Jerry's plan of care. Providing options, even if among limited choices, offers the patient a sense of independence rather than imposing control. Providing structure is crucial, especially in transitioning from a psychiatric to a medical-surgical unit. Encouraging patient input in identifying triggers and effective methods for managing aggressive impulses is essential for empowerment and individualized care. Ensuring the availability and prompt delivery of PRN medications gives the patient a sense of control and security, assuring access to necessary medication when needed.

5. After a needle stick occurs while removing the cap from a sterile needle, which action should the nurse take?

• A. Complete an incident report.
• B. Select another sterile needle.
• C. Disinfect the needle with an alcohol swab.
• D. Notify the supervisor of the department immediately.

Correct answer: B

Rationale: After a needle stick, the needle is considered contaminated and should be discarded. The nurse should select another sterile needle to use. Completing an incident report is not necessary in this situation because the needle was sterile when the nurse was stuck and not in contact with any other person's body fluids. Notifying the supervisor immediately is not required as the situation can be managed by selecting a new needle. Disinfecting the needle with an alcohol swab is not recommended as it does not meet the standards of safe practice and infection control.

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