Nursing Elites

1. What is the most appropriate nursing diagnosis for a patient with agoraphobia who reports not having left their house in months?

• A. Social isolation
• B. Ineffective coping
• C. Risk for injury
• D. Impaired social interaction

Correct answer: A

Rationale: The nursing diagnosis 'Social isolation' is most appropriate for a patient with agoraphobia who has not left their house in months. Agoraphobia often leads to the avoidance of situations or places perceived as unsafe, resulting in social isolation. This diagnosis reflects the patient's limited social interactions and confinement to the home environment, which can impact their overall well-being and mental health. The other options are not as relevant in this scenario: 'Ineffective coping' does not directly address the social withdrawal aspect, 'Risk for injury' is not the primary concern presented, and 'Impaired social interaction' does not capture the extent of isolation described.

2. Tomas is a 21-year-old male with a recent diagnosis of schizophrenia. Tomas’s nurse recognizes that self-medicating with excessive alcohol is common in this disease and can co-occur along with:

• A. Generally good health despite the mental illness.
• B. An aversion to drinking fluids.
• C. Anxiety and depression.
• D. The ability to express his needs.

Correct answer: C

Rationale: Individuals with schizophrenia often turn to alcohol as a form of self-medication to manage co-occurring symptoms of anxiety and depression. This coping mechanism can exacerbate the underlying mental health condition and hinder proper treatment. Recognizing and addressing these co-occurring issues are essential in providing holistic care for individuals with schizophrenia.

3. What is the most appropriate intervention for a patient experiencing severe anxiety?

• A. Encourage the patient to talk about their anxiety.
• B. Teach the patient deep breathing exercises.
• C. Remain with the patient and provide a calm presence.
• D. Suggest the patient engage in physical activity.

Correct answer: C

Rationale: When a patient is experiencing severe anxiety, remaining with the patient and providing a calm presence is the most appropriate intervention. This approach can help the patient feel supported and safe, which can help in reducing their anxiety levels. Encouraging the patient to talk about their anxiety may not be suitable during a severe anxiety episode, as it can potentially escalate their distress. Teaching deep breathing exercises can be helpful, but in cases of severe anxiety, the patient may find it challenging to focus on such techniques. Suggesting physical activity may not be suitable as the patient might not be in a state to engage in such activities when experiencing severe anxiety.

4. What intervention should the nurse implement when caring for a patient demonstrating manic behavior?

• A. Monitor the patient’s vital signs frequently.
• B. Engage the patient in calming activities.
• C. Offer the patient a quiet environment for relaxation.
• D. Reduce environmental stimuli and create a calm atmosphere.

Correct answer: D

Rationale: When caring for a patient demonstrating manic behavior, the nurse should implement the intervention of reducing environmental stimuli and creating a calm atmosphere. This approach is crucial in managing manic behavior as it helps decrease triggers that may worsen the patient's symptoms. Engaging the patient in calming activities (Choice B) may not be effective during a manic episode as the patient may have difficulty focusing. While offering a quiet environment for relaxation (Choice C) is beneficial, it may not be sufficient to address the heightened stimulation experienced during mania. Monitoring the patient’s vital signs frequently (Choice A) is important in general patient care but may not directly address the specific needs of a patient exhibiting manic behavior.

5. What is the priority intervention for a patient admitted for an overdose of sedatives and diagnosed with dissociative identity disorder?

• A. Conducting a suicide assessment
• B. Arranging for placement in a group home
• C. Providing a low-stimulation environment
• D. Establishing trust and rapport

Correct answer: A

Rationale: Conducting a suicide assessment is the priority intervention for a patient admitted for an overdose of sedatives and diagnosed with dissociative identity disorder. In this scenario, the immediate concern is to assess the risk of harm to the patient's life. It is crucial to determine if the overdose was intentional and if the patient has suicidal ideation or intent. Arranging for placement in a group home (choice B) may be necessary at a later stage depending on the patient's needs, but it is not the priority in this urgent situation. Providing a low-stimulation environment (choice C) and establishing trust and rapport (choice D) are important aspects of care but addressing the immediate risk of suicide takes precedence in this case.

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