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 client with schizophrenia is experiencing auditory hallucinations. Which nursing intervention should the nurse implement to address this symptom?

• A. Encourage the client to express feelings about the hallucinations.
• B. Distract the client from the hallucinations.
• C. Provide reality-based feedback about the hallucinations.
• D. Encourage the client to ignore the hallucinations.

Correct answer: C

Rationale: The correct intervention for a client experiencing auditory hallucinations in schizophrenia is to provide reality-based feedback about the hallucinations. By providing reality-based feedback, the nurse helps the client differentiate between what is real and what is not, which can help decrease the distress and impact of the hallucinations on the client's perception of reality. Encouraging the client to express feelings (Choice A) may not directly address the hallucinations. Distracting the client (Choice B) may temporarily alleviate the symptoms but does not help the client differentiate reality from hallucinations. Encouraging the client to ignore the hallucinations (Choice D) may not be effective as the client may struggle to do so without appropriate guidance.

3. 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.

4. A healthcare professional is assessing a client who has been diagnosed with schizoid personality disorder. Which of the following behaviors should the healthcare professional expect?

• A. Preference for solitary activities
• B. Detachment from social relationships
• C. Indifference to praise or criticism
• D. Anxiety in social situations

Correct answer: C

Rationale: The correct behavior that the healthcare professional should expect in an individual with schizoid personality disorder is indifference to praise or criticism. While it is true that individuals with this disorder often exhibit a preference for solitary activities and detachment from social relationships, the key defining characteristic is their emotional detachment and lack of response to external feedback, which includes being indifferent to praise or criticism. Anxiety in social situations is not a typical feature of schizoid personality disorder.

5. A nursing student new to psychiatric-mental health nursing asks a peer what resources he can use to identify the symptoms present in a specific psychiatric disorder. The best answer would be:

• A. Nursing Interventions Classification (NIC)
• B. Nursing Outcomes Classification (NOC)
• C. NANDA-I nursing diagnoses
• D. DSM-5

Correct answer: D

Rationale: The DSM-5 is the standard classification of mental disorders used by mental health professionals in the U.S. It provides criteria for diagnosing different psychiatric disorders based on symptoms and clinical observations. Nursing Interventions Classification (NIC) and Nursing Outcomes Classification (NOC) are focused on nursing interventions and outcomes, respectively, while NANDA-I nursing diagnoses are related to identifying nursing problems and their contributing factors.

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