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. A client diagnosed with borderline personality disorder tells the nurse, 'You are the only one who understands me. The other nurses don't care about me.' Which of the following responses should the nurse make?

• A. Why do you feel that way?
• B. The other nurses care about you too.
• C. You shouldn't say things like that.
• D. I think you are overreacting.

Correct answer: B

Rationale: The correct response is to acknowledge the client's feelings and provide support while also emphasizing that all staff members care about the client's well-being. Choice A does not acknowledge the client's emotions and may come across as dismissive. Choice C invalidates the client's feelings and may make the client feel misunderstood. Choice D minimizes the client's emotions, which can lead to a breakdown in therapeutic communication. Therefore, option B is the most appropriate response as it validates the client's feelings while reinforcing the idea that the entire healthcare team is supportive.

3. A client diagnosed with borderline personality disorder has been admitted to the psychiatric unit after a suicide attempt. Which of the following actions should the nurse take first?

• A. Encourage the client to express feelings about the suicide attempt.
• B. Place the client on one-to-one observation.
• C. Discuss the client's feelings about the suicide attempt.
• D. Encourage the client to participate in group therapy.

Correct answer: B

Rationale: The initial priority for the nurse is to ensure the safety of the client. Placing the client on one-to-one observation allows for constant monitoring and intervention if there are any signs of self-harm or a worsening condition. This immediate intervention is crucial to prevent further harm. Options A, C, and D involve therapeutic communication and interventions, which are important but should come after ensuring the client's safety.

4. Which of the following symptoms shouldn't one expect to assess in a client diagnosed with major depressive disorder?

• A. Loss of interest or pleasure
• B. Decreased ability to concentrate
• C. Significant weight loss or gain
• D. Increased energy

Correct answer: D

Rationale: Symptoms commonly associated with major depressive disorder include a loss of interest or pleasure, decreased ability to concentrate, significant weight loss or gain, and feelings of worthlessness or excessive guilt. Increased energy is not a typical symptom of major depressive disorder; individuals with this condition often experience fatigue rather than increased energy.

5. According to Maslow's hierarchy of needs, which situation on an inpatient psychiatric unit would require priority intervention by a nurse?

• A. A client rudely complaining about limited visiting hours
• B. A client exhibiting aggressive behavior toward another client
• C. A client stating that no one cares
• D. A client verbalizing feelings of failure

Correct answer: B

Rationale: The correct answer is B. According to Maslow's hierarchy of needs, safety needs are considered fundamental and must be addressed before higher-level needs. When a client exhibits aggressive behavior toward another client, it poses an immediate threat to safety and requires priority intervention by the nurse to ensure the well-being of all individuals involved. Clients who are rude in their complaints (Choice A), express feelings of failure (Choice D), or state that no one cares (Choice C) are addressing higher-level needs related to social interactions, esteem, and self-actualization, respectively, which can be addressed once safety needs are secured.

Similar Questions