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. Which of the following is not a common side effect of selective serotonin reuptake inhibitors (SSRIs)?

• A. Nausea
• B. Insomnia
• C. Weight loss
• D. Sexual dysfunction

Correct answer: C

Rationale: Common side effects of SSRIs include nausea, insomnia, weight gain, and sexual dysfunction. Weight loss is not a common side effect associated with SSRIs; instead, weight gain is more frequently observed. Therefore, the correct answer is C.

3. Which of the following interventions is inappropriate for a client experiencing a panic attack?

• A. Provide a well-lit environment.
• B. Encourage deep breathing.
• C. Move the client to a quiet environment.
• D. Administer prescribed antianxiety medication.

Correct answer: A

Rationale: During a panic attack, a well-lit environment might exacerbate the client's symptoms due to sensory overload. Therefore, it is inappropriate to provide a well-lit environment during a panic attack. Encouraging deep breathing, moving the client to a quiet environment, and administering prescribed antianxiety medication are appropriate interventions for managing a panic attack. These actions help create a calming atmosphere and address the physiological symptoms associated with panic attacks.

4. When assessing a client experiencing severe anxiety, which symptom should the nurse expect to observe?

• A. Restlessness
• B. Rapid heart rate
• C. Sweating
• D. Dry mouth

Correct answer: B

Rationale: When a client is experiencing severe anxiety, a rapid heart rate is a common physiological response. This increased heart rate is due to the body's fight-or-flight response, where adrenaline is released, causing the heart to beat faster. Monitoring the client's heart rate is crucial in assessing and managing their anxiety. Restlessness (choice A) can also be present in anxiety but is more of a behavioral manifestation rather than a physiological symptom. Sweating (choice C) can occur in anxiety, but it is not as specific or consistent as a rapid heart rate. Dry mouth (choice D) is associated with anxiety but is not as immediate or directly linked to the body's physiological response to stress as a rapid heart rate.

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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