Nursing Elites

1. A woman was abducted and raped at gunpoint by an unknown assailant. When found, she was confused and disoriented. The nurse makes the following observations about the client. She is talking rapidly in disjointed phrases, is unable to concentrate, and is indecisive when asked to make simple decisions. The client's level of anxiety can be assessed as

• A. moderate
• B. severe
• C. mild
• D. nonexistent

Correct answer: B

Rationale: The client's presentation, including rapid and disjointed speech, inability to concentrate, and indecisiveness, are indicative of severe anxiety. These symptoms suggest a high level of distress and impairment in cognitive functioning, which aligns with severe anxiety rather than mild or moderate levels. The traumatic experience of being abducted and raped at gunpoint would likely contribute to such a severe level of anxiety.

2. A nurse is assessing a client who has been diagnosed with persistent depressive disorder (dysthymia). Which of the following findings should the nurse expect?

• A. Episodes of hypomania
• B. Periods of elevated mood
• C. Lack of interest in activities
• D. Feelings of detachment from one's body

Correct answer: C

Rationale: The correct finding the nurse should expect in a client diagnosed with persistent depressive disorder (dysthymia) is a lack of interest in activities. This disorder is characterized by a chronic depressive mood lasting for at least two years, alongside symptoms such as changes in appetite, fatigue, low self-esteem, and difficulty concentrating. Clients with dysthymia do not typically experience hypomania, periods of elevated mood, or feelings of detachment from one's body, which are more commonly associated with other mood disorders. Therefore, options A, B, and D are incorrect findings for a client with persistent depressive disorder.

3. A client prescribed lithium for bipolar disorder is receiving education from a healthcare provider. Which statement by the client indicates a need for further teaching?

• A. I should avoid eating aged cheeses and processed meats.
• B. I need to maintain a consistent sodium intake.
• C. I should drink plenty of fluids to stay hydrated.
• D. I can take over-the-counter medications without consulting my healthcare provider.

Correct answer: D

Rationale: The correct answer is D. Taking over-the-counter medications without consulting the healthcare provider is not recommended for clients on lithium therapy as there can be potential interactions between lithium and certain medications. It is crucial for clients on lithium to always consult their healthcare provider before taking any over-the-counter medications to ensure the safety and effectiveness of their treatment. Choices A, B, and C are all correct statements that align with managing lithium therapy, emphasizing the importance of dietary restrictions and adequate hydration, as well as monitoring sodium intake to maintain the therapeutic effects of lithium.

4. In a center for women who have been abused, which intervention would the nurse use for a woman whose husband has been abusing her for several years?

• A. Often times you don't need help, you just need to know when to go
• B. Under these circumstances, leaving your husband is the decision to make
• C. This must be very painful for you. We are here to help you
• D. Let's talk about your strengths. You have them, but sometimes they get lost in pain

Correct answer: C

Rationale: Choice C is the most appropriate intervention when working with a woman who has been abused by her husband. It acknowledges the woman's pain, expresses empathy, and offers support, creating a safe space for her to open up and seek help. This response shows understanding and compassion, which are crucial when dealing with individuals experiencing abuse.

5. A client prescribed diazepam for anxiety is receiving education from a healthcare professional. Which statement by the client indicates a need for further teaching?

• A. I can drink alcohol while taking this medication.
• B. I should avoid drinking alcohol while taking this medication.
• C. I should take this medication only when I feel anxious.
• D. I can stop taking this medication when I feel better.

Correct answer: A

Rationale: The correct answer is A. Clients should avoid alcohol while taking diazepam (Valium) as it can potentiate the effects of the medication, leading to excessive sedation and other adverse effects. Mixing alcohol with diazepam can also increase the risk of overdose and other serious complications. Therefore, it is crucial for the client to refrain from consuming alcohol while on this medication to ensure their safety and optimize the therapeutic benefits of diazepam for managing anxiety.

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