Nursing Elites

1. Which statement demonstrates a well-structured attempt at limit setting?

• A. Hitting me when you are angry is unacceptable.
• B. I expect you to behave yourself during dinner.
• C. Come here, right now!
• D. Good boys don't bite.

Correct answer: A

Rationale: Choice A, 'Hitting me when you are angry is unacceptable,' demonstrates a well-structured attempt at limit setting because it clearly defines the unacceptable behavior without ambiguity. This statement sets a clear boundary and clearly communicates the consequence for the behavior. In contrast, choices B, C, and D are less effective in setting limits as they are either vague expectations or commands without specific consequences for crossing the limit.

2. Which of the following is a common side effect of electroconvulsive therapy (ECT)?

• A. Memory loss
• B. Weight gain
• C. Insomnia
• D. Increased appetite

Correct answer: A

Rationale: Memory loss, particularly short-term memory loss, is a common side effect of electroconvulsive therapy (ECT). ECT can affect memory due to its impact on brain function during and after treatment. While the memory issues are often temporary and tend to improve over time, they are important considerations when discussing the risks and benefits of ECT with patients. Choices B, C, and D are incorrect as weight gain, insomnia, and increased appetite are not common side effects of ECT.

3. During an acute panic attack, which intervention should the nurse implement?

• A. Encourage the client to discuss their feelings
• B. Provide a calm environment
• C. Teach the client deep breathing exercises
• D. Leave the client alone to calm down

Correct answer: C

Rationale: During an acute panic attack, the priority intervention is to create a calm and safe environment. Teaching the client deep breathing exercises is crucial as it promotes relaxation and reduces hyperventilation, helping to manage the panic attack effectively. Encouraging the client to discuss their feelings may exacerbate the panic by increasing emotional distress. Providing a busy environment can escalate stress levels rather than alleviate them. Leaving the client alone may lead to feelings of abandonment or worsen the panic attack. Therefore, the most appropriate intervention is to teach deep breathing exercises to help the client regain control and manage the panic attack.

4. Before discharge from the chemical dependency unit, clients are introduced to different community resources. Which of the following resources would be best for a teenage client, who has been abusing over-the-counter sedatives and is ready for discharge in two days?

• A. Detoxification center
• B. Home care
• C. Assertive community team
• D. Twelve-step recovery group

Correct answer: A

Rationale: For a teenage client who has been abusing over-the-counter sedatives and is ready for discharge in two days, the best resource would be a detoxification center. This specialized facility can provide the necessary medical and psychological support to safely manage the withdrawal symptoms associated with substance abuse. It is crucial to ensure a safe and supervised detox process for the client's well-being and successful recovery.

5. A client diagnosed with OCD spends hours bathing and grooming. During a one-on-one interaction, the client discusses the rituals in detail but avoids any feelings that the rituals generate. Which defense mechanism should the nurse identify?

• A. Dissociation
• B. Rationalization
• C. Sublimation
• D. Intellectualization

Correct answer: D

Rationale: Intellectualization is a defense mechanism where an individual focuses on rational, logical explanations to distance themselves from uncomfortable emotions. In this scenario, the client discusses the OCD rituals in a detailed and analytical manner, avoiding the emotional aspects associated with them. This behavior reflects intellectualization rather than dissociation, rationalization, or sublimation. Dissociation involves a disconnection from reality, rationalization is the attempt to justify behaviors, and sublimation is redirecting unacceptable impulses into socially acceptable activities.

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