Nursing Elites

1. A healthcare professional is caring for a group of clients. Which of the following clients should the healthcare professional consider for referral to an assertive community treatment (ACT) group?

• A. A client in an acute care mental health facility who has fallen several times while running down the hallway
• B. A client who lives at home and keeps forgetting to come in for a scheduled monthly antipsychotic injection for schizophrenia
• C. A client in a day treatment program who reports increasing anxiety during group therapy
• D. A client in a weekly grief support group who reports still missing a deceased partner who has been dead for 3 months

Correct answer: B

Rationale: The client who lives at home and repeatedly forgets to come in for a scheduled monthly antipsychotic injection for schizophrenia should be considered for referral to an assertive community treatment (ACT) group. ACT teams provide intensive community-based treatment and support for individuals with severe mental illness who may have difficulty adhering to treatment on their own. Choices A, C, and D do not describe individuals with severe mental illness who have difficulty adhering to treatment or need intensive community-based support, which are the typical candidates for referral to an ACT group.

2. Which characteristic is most commonly associated with dissociative identity disorder?

• A. Frequent nightmares
• B. Auditory hallucinations
• C. Multiple distinct personalities
• D. Chronic fatigue

Correct answer: C

Rationale: Dissociative identity disorder, commonly known as multiple personality disorder, is characterized by the presence of two or more distinct personality states within an individual. These distinct personalities may have their own way of perceiving and interacting with the world, often leading to gaps in memory and a sense of detachment. Frequent nightmares, auditory hallucinations, and chronic fatigue are not primary characteristics of dissociative identity disorder. Option C, multiple distinct personalities, is the hallmark feature of this disorder, making it the correct choice.

3. A client who is at risk for suicide following their partner’s death is speaking with a nurse. Which of the following statements should the nurse make?

• A. “I feel very sorry for the loneliness you must be experiencing.”
• B. “Suicide is not the appropriate way to cope with loss.”
• C. “Losing someone close to you must be very upsetting.”
• D. “I know how difficult it is to lose a loved one.”

Correct answer: C

Rationale: When a client is at risk for suicide, it is crucial for the nurse to acknowledge the emotional impact of losing a loved one without downplaying or judging their feelings. Statement C demonstrates empathy and understanding without making assumptions or providing unsolicited advice, making it the most appropriate response in this situation. Choice A focuses more on the nurse's feelings rather than the client's, which might not effectively address the client's emotional state. Choice B is judgmental and dismissive, which could further isolate the client. Choice D, although empathetic, shifts the focus to the nurse's experience rather than validating the client's feelings.

4. What principle should guide a nurse's fear about 'saying the wrong thing' to a patient in nurse-patient communication?

• A. Patients tend to appreciate a well-meaning person who conveys genuine acceptance, respect, and concern for their situation.
• B. The patient is more interested in talking to you than listening to what you have to say and is not likely to be offended.
• C. Considering the patient's history, there is little chance that the comment will do any actual harm.
• D. Most people with a mental illness have, by necessity, developed a high tolerance for forgiveness.

Correct answer: A

Rationale: Effective nurse-patient communication is guided by the principle that patients value sincere and respectful interactions. A nurse's well-meaning approach that conveys acceptance, respect, and concern helps establish trust and rapport with patients, even if the nurse is apprehensive about making mistakes. It is essential for the nurse to focus on genuine intent and respect for the patient's situation rather than being consumed by the fear of saying something wrong.

5. What assessment findings would indicate lithium toxicity in a patient hospitalized for an acute manic episode?

• A. Shortness of breath, gastrointestinal distress, chronic cough
• B. Ataxia, severe hypotension, large volume of dilute urine
• C. Gastrointestinal distress, thirst, nystagmus
• D. Electroencephalographic changes, chest pain, dizziness

Correct answer: B

Rationale: In a patient suspected of lithium toxicity, the presence of ataxia, severe hypotension, and a large volume of dilute urine are key assessment findings. Ataxia is a sign of central nervous system involvement, severe hypotension indicates cardiovascular effects, and a large volume of dilute urine suggests renal impairment, all of which are commonly seen in severe lithium toxicity. Options A, C, and D do not align with typical signs of lithium toxicity.

Similar Questions