Nursing Elites

1. A client diagnosed with post-traumatic stress disorder (PTSD) is being assessed by a healthcare professional. Which symptom would the healthcare professional expect the client to exhibit?

• A. Delusions of grandeur
• B. Hypervigilance
• C. Obsessive-compulsive behaviors
• D. Periods of excessive sleeping

Correct answer: B

Rationale: In individuals with post-traumatic stress disorder (PTSD), hypervigilance is a common symptom. Hypervigilance refers to a state of increased alertness, awareness, and sensitivity to potential threats or danger. This heightened state of vigilance can manifest as being easily startled, having difficulty relaxing or sleeping, and constantly scanning the environment for signs of danger. It is an adaptive response to the trauma experienced and can significantly impact the individual's daily functioning. The other options are not typically associated with PTSD. Delusions of grandeur are more commonly seen in certain psychiatric disorders like bipolar disorder or schizophrenia. Obsessive-compulsive behaviors are characteristic of obsessive-compulsive disorder (OCD), not PTSD. Periods of excessive sleeping may be seen in conditions like depression, but they are not a hallmark symptom of PTSD.

2. While auditing care plans for clients with eating disorders, the nurse realizes that a nursing diagnosis appropriate for a client with anorexia nervosa as well as for a client with bulimia nervosa is

• A. Risk for imbalanced body temperature
• B. Ineffective denial
• C. Chronic low self-esteem
• D. Adult failure to thrive

Correct answer: C

Rationale: Chronic low self-esteem is a nursing diagnosis that can be applicable to clients with both anorexia nervosa and bulimia nervosa. These eating disorders are often associated with distorted body image, feelings of inadequacy, and low self-esteem. Clients with these conditions may engage in harmful behaviors related to their self-image, making chronic low self-esteem a relevant nursing diagnosis for them.

3. April, a 10-year-old admitted to inpatient pediatric care, has been getting more and more wound up and is losing self-control in the day room. Time-out does not appear to be an effective tool for April to engage in self-reflection. April's mother admits to putting her in time-out up to 20 times a day. The nurse recognizes that:

• A. Time-out is an important part of April's baseline discipline.
• B. Time-out is no longer an effective therapeutic measure.
• C. April enjoys time-out, and acts out to get some alone time.
• D. Time-out will need to be replaced with seclusion and restraint.

Correct answer: B

Rationale: Frequent use of time-out has reduced its effectiveness as a therapeutic measure for April.

4. During an acute panic attack, which intervention should the nurse implement?

• A. Encourage the client to discuss their feelings
• B. Provide a calm environment
• C. Teach the client deep breathing exercises
• D. Leave the client alone to calm down

Correct answer: C

Rationale: During an acute panic attack, the priority intervention is to create a calm and safe environment. Teaching the client deep breathing exercises is crucial as it promotes relaxation and reduces hyperventilation, helping to manage the panic attack effectively. Encouraging the client to discuss their feelings may exacerbate the panic by increasing emotional distress. Providing a busy environment can escalate stress levels rather than alleviate them. Leaving the client alone may lead to feelings of abandonment or worsen the panic attack. Therefore, the most appropriate intervention is to teach deep breathing exercises to help the client regain control and manage the panic attack.

5. When assessing a client with suspected bipolar disorder, which of the following findings should the nurse not expect?

• A. Periods of elevated mood
• B. Decreased need for sleep
• C. Flight of ideas
• D. Anhedonia

Correct answer: D

Rationale: In bipolar disorder, common findings include periods of elevated mood, decreased need for sleep, and flight of ideas. Anhedonia, the inability to feel pleasure, is more indicative of conditions like major depressive disorder. Therefore, the nurse should not expect to find anhedonia in a client with suspected bipolar disorder.

Similar Questions