Nursing Elites

1. A female adolescent has anorexia nervosa and is malnourished and severely underweight. Which statement indicates that she is experiencing secondary gains from her behavior?

• A. "I'm huge; I'm as big as a house."
• B. "I get straight A's in all my subjects."
• C. "My mother keeps trying to get me to eat."
• D. "My hair is beginning to fall out in clumps."

Correct answer: C

Rationale: The statement "My mother keeps trying to get me to eat" indicates that the adolescent is experiencing secondary gains from her behavior. This is because the behavior has garnered attention from her mother, providing a sense of power and control, which are considered secondary gains. The statement "I'm huge; I'm as big as a house" reflects a disturbed body perception and is not related to secondary gains. Getting straight A's in all subjects is an achievement but not a secondary gain related to anorexia nervosa. The hair falling out in clumps is a physical consequence of starvation, not a secondary gain.

2. A woman who had a mastectomy is scheduled for a mastectomy peer support visit arranged by her primary health care provider. What is the purpose of the referral?

• A. To teach arm exercises
• B. To prevent social isolation
• C. To meet her physical needs
• D. To view her surgical incision

Correct answer: B

Rationale: The purpose of a mastectomy peer support visit is to prevent social isolation. This visit helps the client maintain her social connections and learn about community resources. Teaching arm exercises and meeting physical needs are tasks for healthcare professionals, not the primary goal of a peer support visit. Viewing the surgical incision is also not the primary purpose of such a visit.

3. A community hospital is opening a mental health services department. Which document should the nurse use to develop the unit's nursing guidelines?

• A. Americans with Disabilities Act of 1990
• B. ANA Code of Ethics with Interpretive Statements
• C. ANA's Scope and Standards of Nursing Practice
• D. Patient's Bill of Rights of 1990

Correct answer: C

Rationale: The correct document the nurse should use to develop the unit's nursing guidelines for the mental health services department is ANA's Scope and Standards of Nursing Practice. This document specifically outlines the philosophy and standards of nursing practice, including psychiatric nursing. Option A, the Americans with Disabilities Act of 1990, and option D, the Patient's Bill of Rights of 1990, focus on client rights and legal protections rather than nursing practice guidelines. Option B, the ANA Code of Ethics with Interpretive Statements, provides ethical guidelines for nursing practice but does not specifically address the development of nursing guidelines for a mental health services department.

4. During the first meeting of a therapy group, members exhibit frequent periods of silence, tense laughter, and nervous movements. Which conclusion would the nurse make?

• A. The group requires an active leader who will intervene to relieve signs of obvious stress.
• B. The group process is unhealthy and there is unwillingness to openly relate.
• C. The members are displaying expected behaviors because relationships are not yet established.
• D. The behaviors should be immediately addressed so members will not become too uncomfortable.

Correct answer: C

Rationale: During the initial stages of a therapy group, it is common for members to exhibit behaviors such as silence, tense laughter, and nervous movements. These behaviors indicate anxiety and insecurity due to the lack of established relationships and trust among the group members. This is a normal part of group development, and it does not necessarily mean that the group process is unhealthy. Intervening or addressing these behaviors immediately is not required as they are expected in the early stages of group interaction. As the group progresses and relationships are built, these behaviors are likely to diminish naturally without the need for active leader intervention. Therefore, the correct conclusion is that the members are displaying expected behaviors because relationships are not yet established. Choices A, B, and D are incorrect because active leader intervention is not necessary, the group process is not unhealthy, and addressing the behaviors immediately is not required as they are part of the early group dynamics and are expected to subside as relationships develop.

5. A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take first?

• A. Inform the client that the blood pressure is high and compare the reading with the client's previously documented blood pressure readings for accuracy.
• B. Contact the health care provider to report the reading and obtain a prescription for an antihypertensive medication.
• C. Replace the cuff with a larger one to ensure a proper fit for the client and increase arm comfort during blood pressure measurement.
• D. Compare the current reading with the client's previously documented blood pressure readings.

Correct answer: D

Rationale: The correct action for the nurse to take first when a client's blood pressure reading is 156/94 mm Hg is to compare the current reading with the client's previously documented readings. This comparison helps determine whether the current reading is abnormal for the client. Option A, which involves informing the client that the blood pressure is high and comparing it with the previous readings, is appropriate as it educates the client and aids in accurate assessment. Option B, contacting the health care provider for medication, is premature without further assessment. Option C, replacing the cuff with a larger one, is incorrect as it may affect the accuracy of the blood pressure measurement and is not a standard practice for managing high blood pressure readings.

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