Nursing Elites

1. In an outpatient mental health clinic, a nurse is preparing to conduct an initial client interview. Which of the following actions should the nurse identify as a priority?

• A. Coordinate holistic care with social services
• B. Identify the client’s perception of their mental health status
• C. Include the client’s family in the interview
• D. Educate the client about their current mental health disorder

Correct answer: B

Rationale: During an initial client interview in a mental health clinic, it is essential for the nurse to prioritize identifying the client’s perception of their mental health status. Understanding how the client views their mental health can provide valuable insights into their condition, concerns, and needs, facilitating the development of a tailored and effective care plan. Coordinating holistic care with social services, including the client’s family in the interview, and educating the client about their current mental health disorder are important aspects of care but may not be the priority during the initial interview, where understanding the client's own perspective is crucial.

2. After a severe automobile accident, Mr. and Mrs. Johnson were brought to the hospital. Mrs. Johnson is unable to remember anything about the accident or the two days preceding it. The nurse recognizes this as:

• A. Generalized amnesia
• B. Localized amnesia
• C. Selective amnesia
• D. Continuous amnesia

Correct answer: B

Rationale: Localized amnesia refers to an inability to recall specific events, often traumatic, within a particular time frame. In this case, Mrs. Johnson's memory loss about the accident and the preceding two days aligns with the characteristics of localized amnesia. Generalized amnesia involves a more extensive memory loss, often encompassing a person's entire life, which is not the case here. Selective amnesia involves forgetting specific details but not a whole chunk of time like in this scenario. Continuous amnesia is not a recognized term in psychology.

3. When a patient with schizophrenia is taking haloperidol, what is a priority assessment for the nurse?

• A. Assessing for signs of tardive dyskinesia
• B. Monitoring for signs of neuroleptic malignant syndrome
• C. Checking for signs of depression
• D. Monitoring for changes in appetite

Correct answer: B

Rationale: Monitoring for signs of neuroleptic malignant syndrome is crucial for patients taking haloperidol. Neuroleptic malignant syndrome is a rare but serious side effect that can occur with antipsychotic medications like haloperidol. It presents with symptoms such as high fever, unstable blood pressure, confusion, muscle rigidity, and autonomic dysfunction. Early detection and intervention are essential to prevent serious complications.

4. A client is undergoing systematic desensitization for an extreme fear of elevators. Which of the following actions should be implemented with this form of therapy?

• A. Demonstrate riding in an elevator, then ask the client to imitate the behavior.
• B. Advise the client to say “stop” out loud every time they begin to feel an anxiety response related to an elevator.
• C. Gradually expose the client to an elevator while practicing relaxation techniques.
• D. Stay with the client in an elevator until the anxiety response diminishes.

Correct answer: C

Rationale: Systematic desensitization is a type of therapy used to help individuals overcome phobias or anxieties. It involves gradually exposing the client to the feared object or situation, in this case, an elevator, while simultaneously practicing relaxation techniques. This process helps the client associate relaxation with the previously feared stimulus, gradually reducing anxiety levels over time. Choice A is incorrect as it involves imitation rather than gradual exposure. Choice B is incorrect as it focuses on a verbal response rather than the systematic process of exposure and relaxation. Choice D is incorrect as it does not involve the systematic approach of gradually exposing the client while teaching relaxation techniques.

5. A community mental health nurse is planning care to address the issue of depression among older adult clients in the community. Which of the following interventions should the nurse implement as a method of tertiary prevention?

• A. Educating clients on health promotion techniques to reduce the risk of depression
• B. Performing screenings for depression at community health programs
• C. Establishing rehabilitation programs to decrease the effects of depression
• D. Providing support groups for clients at risk for depression

Correct answer: C

Rationale: Establishing rehabilitation programs to decrease the effects of depression is a method of tertiary prevention.

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