Nursing Elites

1. A client states, 'I am the only one who can hear voices.' Which is the nurse's best response?

• A. Tell me more about these voices.
• B. Let's explore these voices together.
• C. How long have you been hearing these voices?
• D. Have you told anyone else about these voices?

Correct answer: A

Rationale: The best response for the nurse is to encourage the client to talk about their experiences with hearing voices. By asking the client to share more details about the voices, the nurse can gain insight into the nature of the auditory hallucinations and better understand the client's condition. This open-ended question allows the client to express themselves freely and helps build rapport and trust between the client and the nurse. Choices B, C, and D do not directly address the client's statement or encourage further elaboration, making them less effective responses in this context.

2. A client is being assessed by a nurse after being diagnosed with anorexia nervosa. Which of the following findings should the nurse expect?

• A. Weight gain and increased appetite
• B. Lanugo on the face and back
• C. Increased body temperature and tachycardia
• D. Hyperactivity and distractibility

Correct answer: B

Rationale: In anorexia nervosa, individuals often develop lanugo, fine soft hair, on the face and back. This is a physiological response to the body's attempt to conserve heat due to a lack of subcutaneous fat. It is a common physical finding in clients with anorexia nervosa and can be a sign of severe malnutrition. Choices A, C, and D are incorrect because weight gain and increased appetite, increased body temperature and tachycardia, and hyperactivity and distractibility are not typically associated with anorexia nervosa. In fact, weight loss, decreased appetite, hypothermia, and bradycardia are more commonly seen in individuals with anorexia nervosa.

3. During an intake assessment, a healthcare professional asks both physiological and psychosocial questions. The client angrily responds, 'I'm here for my heart, not my head problems.' What is the healthcare professional's best response?

• A. It's just a routine part of our assessment. All clients are asked these same questions.
• B. Why are you concerned about these types of questions?
• C. Psychological factors, like excessive stress, have been found to affect medical conditions.
• D. We can skip these questions, if you like. It isn't imperative that we complete this section.

Correct answer: C

Rationale: The healthcare professional should educate the client on the negative effects of excessive stress on medical conditions. Understanding the interconnectedness of physical and mental health is crucial for providing holistic care. Choice A is incorrect because it doesn't address the importance of psychosocial aspects. Choice B is wrong as it doesn't provide relevant information about the impact of psychological factors on health. Choice D is incorrect because skipping questions would lead to an incomplete assessment, potentially missing crucial information affecting the client's overall health outcomes.

4. A client with schizophrenia is prescribed an antipsychotic medication. Which of the following side effects should the nurse monitor for? Select one that does not apply.

• A. Tardive dyskinesia
• B. Neuroleptic malignant syndrome
• C. Mindfulness meditation
• D. Hyperglycemia

Correct answer: C

Rationale: The correct answer is C, 'Mindfulness meditation.' Side effects of antipsychotic medications include tardive dyskinesia, neuroleptic malignant syndrome, orthostatic hypotension, and hyperglycemia. Mindfulness meditation is not a side effect of antipsychotic medications. Choices A, B, and D are all potential side effects of antipsychotic medications. Tardive dyskinesia is a movement disorder characterized by repetitive, involuntary movements. Neuroleptic malignant syndrome is a rare but life-threatening reaction to antipsychotic medication. Hyperglycemia can occur as a side effect of some antipsychotic medications, particularly the second-generation ones.

5. Which statement made by the nurse demonstrates the best understanding of nonverbal communication?

• A. The patient's verbal and nonverbal communication is often different.
• B. When my patient responds to my question, I check for congruence between verbal and nonverbal communication to help validate the response.
• C. If a patient is slumped in the chair, I can be sure he's angry or depressed.
• D. It's easier to understand verbal communication than nonverbal communication.

Correct answer: B

Rationale: Checking for congruence between verbal and nonverbal communication helps validate the patient's response.

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