Nursing Elites

1. Which of the following is an appropriate tension-reduction intervention for a patient who may be escalating toward aggressive behavior?

• A. Asking to speak to someone
• B. Asking to be alone
• C. Listening to music
• D. All of the above

Correct answer: D

Rationale: All of the above interventions are appropriate tension-reduction techniques for a patient in the ICU. When a patient is escalating toward aggressive behavior, it is crucial to have a range of strategies to help de-escalate the situation. Asking to speak to someone can provide emotional support and an outlet for communication. Asking to be alone can help the patient have space and time to calm down. Listening to music can be soothing and distracting. These interventions, along with additional ones like walking the hallway, watching television, writing in a journal, or requesting a PRN medication, can be helpful. It is essential to involve the patient in developing the care plan to identify triggers and effective tension-reduction techniques. Patients in escalation may not always recognize the need for intervention, so staff must be observant and offer personalized techniques to address the situation effectively.

2. For a client with obsessive-compulsive disorder, which reaction is most likely to occur when the performance of a ritual is interrupted?

• A. Anxiety
• B. Hostility
• C. Aggression
• D. Withdrawal

Correct answer: A

Rationale: When a client with obsessive-compulsive disorder is interrupted while performing a ritual, the most likely reaction is anxiety. The compulsive ritual serves as a coping mechanism to control anxiety, so any disruption to this ritual can heighten the individual's anxiety levels. Hostility is typically part of the disorder itself and not a direct reaction to the interruption of the ritual. Aggression may occur only if anxiety escalates to a panic level, leading to overt anger expression. Withdrawal is not a common behavioral pattern associated with obsessive-compulsive disorder and is not a typical reaction to ritual interruption.

3. Which term describes what an adolescent client is experiencing when she says to the nurse who has been caring for her, 'You're just like my mother; I hate you'?

• A. Insight
• B. Universality
• C. Transference
• D. Identification

Correct answer: C

Rationale: Transference occurs when a client unconsciously assigns feelings and attitudes originally associated with another important person in the client's life. In this scenario, the adolescent client is projecting emotions connected to her mother onto the nurse. This client's statement does not demonstrate insight but rather reflects the mechanism of transference. Universality refers to the sense that one is not alone in any situation, which is not evident in the client's statement. Identification is a defense mechanism where an individual takes on characteristics of someone considered admirable, which is not the case in this situation.

4. An ambulatory client reports edema during the day in his feet and an ankle that disappears while sleeping at night. What is the most appropriate follow-up question for the nurse to ask?

• A. Have you had a recent heart attack?
• B. Do you become short of breath during your normal daily activities?
• C. How many pillows do you use at night to sleep comfortably?
• D. Do you smoke?

Correct answer: B

Rationale: The correct answer is asking about shortness of breath during normal daily activities because these symptoms suggest right-sided heart failure, leading to increased pressure in the systemic venous system. This pressure causes fluid to shift into the interstitial spaces, resulting in edema. In an ambulatory patient, lower extremities are typically affected first due to gravity. By asking about shortness of breath, the nurse can gather information to confirm the nursing diagnosis of activity intolerance and fluid volume excess, both associated with right-sided heart failure. The other choices are less relevant in this context and do not directly address the client's presenting symptoms.

5. Identify the type of 'trigger' with the correct 'trigger' that can possibly lead to disturbed behavior.

• A. Emotional: room coldness
• B. Environmental: boredom
• C. Physical: pain
• D. Communication: silence

Correct answer: C

Rationale: Physical pain is a common trigger that can lead to disturbed behavior in individuals, especially when they are unable to communicate their pain effectively. Choices A, B, and D are incorrect. Room coldness falls under environmental triggers, boredom is associated with emotional triggers, and silence is a communication aspect rather than a direct trigger for disturbed behavior.

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