Nursing Elites

1. A client with borderline personality disorder exhibits self-mutilating behavior. Which nursing intervention should the nurse implement to address this behavior?

• A. Encourage the client to discuss underlying issues.
• B. Set firm limits on the client's behavior.
• C. Provide a safe environment to prevent self-harm.
• D. Discuss the consequences of self-mutilating behavior.

Correct answer: C

Rationale: The correct intervention when dealing with a client exhibiting self-mutilating behavior, especially with borderline personality disorder, is to provide a safe environment to prevent self-harm. This approach is crucial in ensuring the client's physical safety and well-being. Setting firm limits may be appropriate in some situations, but the immediate priority is to prevent self-harm. Encouraging the client to discuss underlying issues and discussing consequences are important aspects of therapy; however, in the case of acute self-mutilating behavior, the primary focus should be on creating a safe environment to prevent harm.

2. Which of the following are common side effects of selective serotonin reuptake inhibitors (SSRIs)? Select one that does not apply.

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

Correct answer: C

Rationale: Common side effects of selective serotonin reuptake inhibitors (SSRIs) include nausea, insomnia, weight gain, and sexual dysfunction. Weight loss is not a common side effect associated with SSRIs. Therefore, the correct answer is C. While some individuals may experience weight changes while taking SSRIs, weight loss is less common compared to weight gain as a side effect of these medications.

3. During an assessment, a nurse observes a client showing signs of moderate anxiety. Which symptom is not typically associated with moderate anxiety?

• A. Fidgeting
• B. Laughing inappropriately
• C. Palpitations
• D. Nail biting

Correct answer: C

Rationale: When assessing a client with moderate anxiety, the nurse should anticipate signs such as fidgeting, laughing inappropriately, and nail biting. These behaviors are common manifestations of increased stress levels. Palpitations, on the other hand, are more commonly associated with severe anxiety or panic attacks. Other symptoms of severe anxiety may include restlessness, difficulty concentrating, muscle tension, and sleep disturbances.

4. Child protective services have removed 10-year-old Christopher from his parents' home due to neglect. Christopher reveals to the nurse that he considers the woman next door his 'nice' mom, that he loves school, and gets above-average grades. The strongest explanation of this response is:

• A. Temperament
• B. Genetic factors
• C. Resilience
• D. Paradoxical effects of neglect

Correct answer: C

Rationale: Christopher's positive outlook, strong school performance, and forming a bond with the neighbor indicate resilience. Resilience refers to the ability to adapt and thrive despite facing adversity, such as being removed from his parents' home due to neglect. His ability to maintain a positive attitude and excel in school despite the challenging circumstances highlights his resilience.

5. A nursing instructor is teaching a group of students about intimate partner violence. Which response by the students indicates no further teaching is needed?

• A. Alaska Native women report the highest rate of intimate partner violence.
• B. Caucasian women report the lowest rate of intimate partner violence.
• C. African American women report the highest rate of intimate partner violence.
• D. Asian women report the lowest rate of intimate partner violence.

Correct answer: A

Rationale: The correct answer is A. Alaska Native women do report the highest rate of intimate partner violence. This statistic is important for healthcare professionals to be aware of to provide culturally sensitive care and interventions. Choices B, C, and D are incorrect statements. While it is essential to understand disparities in intimate partner violence rates among different populations, in this context, the focus is on recognizing the accurate information provided about Alaska Native women.

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