Nursing Elites

1. Which defense mechanism would the nurse conclude a female client with obsessive-compulsive disorder, who washes her hands more than 20 times a day, is using to ease anxiety?

• A. Undoing
• B. Projection
• C. Introjection
• D. Displacement

Correct answer: A

Rationale: The correct answer is 'Undoing.' Undoing is a defense mechanism where the individual tries to negate a previous act to relieve guilt or anxiety. In this case, the client washing her hands excessively is trying to 'undo' perceived contamination or guilt associated with not washing. Projection (choice B) involves attributing one's own unacceptable thoughts or impulses to others, which is not demonstrated in this scenario. Introjection (choice C) is the process of internalizing beliefs or values of others, which is also not applicable in this context. Displacement (choice D) involves redirecting emotions from one target to another, which does not align with the client's behavior of handwashing as a response to anxiety in this case.

2. For which condition would electroconvulsive therapy (ECT) be used?

• A. Severe clinical depression
• B. Substance abuse disorders
• C. Antisocial personality disorder
• D. Psychosis occurring in schizophrenia

Correct answer: A

Rationale: Electroconvulsive therapy (ECT) is indicated for severe clinical depression, especially in cases where clients do not respond well to psychotropic medications or require immediate intervention due to the severity of their depression. ECT is not typically used as a primary treatment for substance abuse disorders, antisocial personality disorder, or psychosis occurring in schizophrenia. While ECT is an effective intervention for severe depression, it is important to consider individual client needs and response to other treatment options before resorting to ECT.

3. The client prepares to insert a nasogastric tube in a client with hyperemesis who is awake and alert. Which intervention(s) is(are) correct?

• A. Place the client in a high Fowler position.
• B. Assist the client in assuming a left side-lying position.
• C. Measure the tube from the tip of the nose to the xiphoid process.
• D. Assist the client in flexing the neck forward to facilitate tube insertion.

Correct answer: A

Rationale: The correct intervention during nasogastric tube insertion in an awake and alert client is to place them in a high Fowler position (A). Left side-lying position (B) is more suitable for unconscious or obtunded clients. When measuring the tube length, it should be from the tip of the nose to behind the ear, and then from behind the ear to the xiphoid process (C). Assisting the client in flexing the neck forward (D) is appropriate to facilitate tube insertion rather than extending the neck back, which may lead to complications. Proper positioning and measurements are crucial to prevent complications and ensure successful nasogastric tube placement.

4. A client who is at 28 weeks' gestation and in active labor is crying. She says, 'I just know that this baby is going to die. What's the use of doing all this to save it?' Which explanation would interpret the client's statements?

• A. She is depressed and needs gentle, positive support during labor.
• B. She is experiencing anticipatory grief and withdrawing from bonding.
• C. She is in need of emotional support to help her cope with the impending birth.
• D. She is struggling to cope with the birth by using the word 'it.'

Correct answer: B

Rationale: The client's statement indicates anticipatory grief, where she is preparing for a potential loss. This grief is not necessarily about the literal death of the baby but about the loss of the anticipated healthy full-term baby. The client may not be ready to bond with the reality of a preterm baby. Providing gentle, positive support is essential to help her cope with her feelings, as firm support may come across as dismissive. Sedation is not appropriate as it could hinder the client's emotional processing. Allowing the client to express her emotions and work through anticipatory grieving is crucial. The use of the word 'it' reflects the client's emotional struggle and is not the primary issue at hand.

5. Which instruction is most important for the nurse to include when teaching a client with limited mobility strategies to prevent venous thrombosis?

• A. Perform cough and deep breathing exercises hourly.
• B. Turn from side to side in bed at least every 2 hours.
• C. Dorsiflex and plantarflex the feet 10 times each hour
• D. Drink approximately 4 ounces of water every hour

Correct answer: C

Rationale: To reduce the risk of venous thrombosis, the nurse should instruct the client to perform dorsiflexion and plantar flexion exercises regularly. These exercises help promote venous return and prevent venous thrombus formation. Options A, B, and D are beneficial in managing other complications of immobility, such as atelectasis and pressure ulcers, but they are less effective in preventing venous thrombosis compared to dorsiflexion and plantar flexion exercises.

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