Nursing Elites

1. A female client with schizophrenia tells the nurse that she believes her brain is controlled by the CIA. The nurse recognizes this as which type of delusion?

• A. Somatic delusion
• B. Paranoid delusion
• C. Persecutory delusion
• D. Grandiose delusion

Correct answer: C

Rationale: The correct answer is C: Persecutory delusion. Persecutory delusions involve beliefs of being conspired against, watched, or harassed by others, which is a common symptom in schizophrenia. In this scenario, the client's belief that her brain is controlled by the CIA aligns with persecutory delusions as she feels targeted or manipulated by an external entity. Choices A, B, and D are incorrect. Somatic delusions involve false beliefs about one's body functions or sensations, paranoid delusions involve irrational suspicions and mistrust of others, and grandiose delusions involve exaggerated beliefs of one's importance or abilities.

2. A client who is diagnosed with schizophrenia is admitted to the hospital. The nurse assesses the client's mental status. Which assessment finding is most characteristic of a client with schizophrenia?

• A. Mood swings.
• B. Extreme sadness.
• C. Manipulative behavior.
• D. Flat affect.

Correct answer: D

Rationale: The correct answer is D: Flat affect. Flat affect, which is a lack of emotional expression, is highly characteristic of schizophrenia. Mood swings (choice A) are more indicative of mood disorders rather than schizophrenia. Extreme sadness (choice B) could be seen in depression but is not as specific to schizophrenia. Manipulative behavior (choice C) is not a defining characteristic of schizophrenia; it may be seen in various psychiatric conditions but is not the most characteristic feature of schizophrenia.

3. A 22-year-old male client is admitted to the emergency center following a suicide attempt. His records reveal that this is his third suicide attempt in the past two years. He is conscious, but does not respond to verbal commands for treatment. Which assessment finding should prompt the nurse to prepare the client for gastric lavage?

• A. He ingested the drug 3 hours prior to admission to the emergency center.
• B. The family reports that he took an entire bottle of acetaminophen (Tylenol).
• C. He is unresponsive to instructions and is unable to cooperate with emetic therapy.
• D. Those with repeated suicide attempts desire punishment to relieve their guilt.

Correct answer: C

Rationale: The correct answer is C because the client's unresponsiveness to instructions and inability to cooperate with emetic therapy would make it challenging to implement such therapy effectively. In such cases, gastric lavage may be necessary to remove the ingested substance. Choices A and B are important considerations in treatment planning but do not directly indicate the need for gastric lavage. Choice D is incorrect as medical treatments should never be used as punitive measures but rather for therapeutic purposes.

4. The nurse is caring for a client who received the first-time electroconvulsive therapy (ECT) a half hour ago. Which action should the nurse implement first?

• A. Offer oral fluids.
• B. Monitor vital signs.
• C. Evaluate ECT effectiveness.
• D. Encourage group participation.

Correct answer: B

Rationale: After a client receives electroconvulsive therapy (ECT), the nurse's priority should be to monitor vital signs. This is important to ensure the client's physical stability and detect any immediate complications post-procedure. Offering oral fluids, evaluating ECT effectiveness, and encouraging group participation are all important aspects of care but monitoring vital signs takes precedence in the immediate post-ECT period.

5. A 45-year-old female client is admitted to the psychiatric unit for evaluation. Her husband states that she has been reluctant to leave home for the last six months. The client has not gone to work for a month and has been terminated from her job. She has not left the house since that time. This client is displaying symptoms of what condition?

• A. Claustrophobia
• B. Acrophobia
• C. Agoraphobia
• D. Post-traumatic stress disorder

Correct answer: C

Rationale: The correct answer is C: Agoraphobia. Agoraphobia is the fear of crowds or being in open places, often leading individuals to avoid situations where they feel trapped, insecure, or out of control. In the case described, the client's reluctance to leave home, avoidance of work, and isolation within the house are indicative of agoraphobia. Claustrophobia (A) is the fear of closed places, while acrophobia (B) is the fear of high places. Post-traumatic stress disorder (D) involves the development of anxiety symptoms following a traumatic event, characterized by terror, fear, and helplessness, and is different from a phobia.

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