Nursing Elites

1. While assessing a distraught female high school student who is overly concerned because her parents can't afford horseback riding lessons, how should the nurse interpret the student's reaction to her perceived problem?

• A. The problem is endangering her well-being.
• B. The problem is personally relevant to her.
• C. The problem is based on immaturity.
• D. The problem is exceeding her capacity to cope.

Correct answer: B

Rationale: In this scenario, the student being overly concerned about not being able to afford horseback riding lessons indicates that the problem is personally relevant to her. Psychological stressors related to self-esteem and self-image are influenced by how an individual perceives a situation or event. Adolescents, in particular, place significance on self-image and feeling entitled to experiences that other adolescents have, which can lead to distress when such desires are not met. Choice A is incorrect because there is no indication that the student's physical well-being is at risk. Choice C is incorrect as it simplifies the issue by attributing it solely to immaturity. Choice D is incorrect as there is no evidence provided that the problem is beyond the student's coping abilities.

2. When caring for a client with anorexia nervosa in a psychiatric unit, which intervention should the nurse implement to address the client's nutritional needs?

• A. Provide small, frequent meals throughout the day.
• B. Monitor the client's weight daily.
• C. Offer a liquid supplement if the client refuses solid food.
• D. Encourage the client to choose from a variety of food options.

Correct answer: A

Rationale: Providing small, frequent meals throughout the day is a crucial intervention when caring for a client with anorexia nervosa. This approach helps in gradually increasing caloric intake and meeting the client's nutritional needs. Offering large meals can be overwhelming and may contribute to anxiety in these clients. By providing small, frequent meals, the nurse supports the client in establishing a healthier eating pattern and aids in the restoration of adequate nutrition levels. Monitoring the client's weight daily (Choice B) may exacerbate anxiety related to body image and weight, which are common concerns in anorexia nervosa. Offering a liquid supplement if the client refuses solid food (Choice C) may not address the underlying issues related to food aversion and may not provide the necessary nutrients in a balanced way. Encouraging the client to choose from a variety of food options (Choice D) may be overwhelming for someone with anorexia nervosa and could lead to increased anxiety around food choices.

3. Which of the following is identified as a psychoneurotic response to severe anxiety as it appears in the DSM-5?

• A. Somatic symptom disorder
• B. Grief responses
• C. Psychosis
• D. Bipolar disorder

Correct answer: A

Rationale: The correct answer is A: Somatic symptom disorder. Somatic symptom disorder is characterized by preoccupation with physical symptoms for which there is no demonstrable organic pathology. One of the diagnostic criteria is a high level of anxiety about health concerns or illness. In the DSM-5, somatic symptom disorders are classified under the category of somatic symptom and related disorders, which encompass conditions where psychological factors play a significant role in the development, exacerbation, or maintenance of physical symptoms. Choices B, C, and D are incorrect. Grief responses, psychosis, and bipolar disorder are not specifically categorized as psychoneurotic responses to severe anxiety in the DSM-5.

4. A client with a history of alcohol use disorder is admitted to the hospital for detoxification. Which of the following symptoms shouldn't the nurse expect to observe during withdrawal?

• A. Tremors
• B. Hallucinations
• C. Diaphoresis
• D. Bradycardia

Correct answer: D

Rationale: During alcohol withdrawal, the nurse should expect to observe symptoms such as tremors, hallucinations, and diaphoresis. Seizures may also occur during severe withdrawal. Bradycardia is not typically associated with alcohol withdrawal; instead, tachycardia (an increased heart rate) is more commonly observed due to the stimulant effects of alcohol withdrawal on the sympathetic nervous system.

5. A client with obsessive-compulsive disorder (OCD) is being cared for by a nurse. Which intervention should the nurse include in the plan of care?

• A. Encourage the client to suppress compulsive behaviors.
• B. Set strict limits on the amount of time the client can engage in compulsive behaviors.
• C. Allow the client to perform compulsive behaviors as needed.
• D. Gradually limit the amount of time allotted for compulsive behaviors.

Correct answer: D

Rationale: In caring for a client with OCD, it is essential to gradually limit the time allotted for compulsive behaviors. This intervention helps the client develop alternative coping mechanisms. Encouraging suppression or setting strict limits on compulsive behaviors can exacerbate the client's anxiety, making it crucial to approach the care plan with a gradual reduction strategy. Allowing the client to perform compulsive behaviors as needed does not promote progress towards managing OCD symptoms and may reinforce maladaptive patterns of behavior.

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