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. How does emotional trauma typically affect individuals physically?

• A. Emotional trauma is a distinct category and unrelated to physical symptoms.
• B. Physical manifestations of emotional trauma are usually temporary.
• C. Emotional trauma is often manifested as physical symptoms.
• D. Patients are more aware of physical problems caused by trauma.

Correct answer: C

Rationale: Emotional trauma can often manifest as physical symptoms, such as headaches, stomachaches, and other somatic complaints. These physical manifestations can be long-lasting and impact the individual's overall well-being.

3. Which drug group requires nursing assessment for the development of abnormal movement disorders in individuals taking therapeutic dosages?

• A. SSRIs
• B. Antipsychotics
• C. Benzodiazepines
• D. Tricyclic antidepressants

Correct answer: B

Rationale: Antipsychotics are known to cause extrapyramidal symptoms, which manifest as abnormal movement disorders. Nursing assessments are crucial in monitoring patients taking antipsychotics to promptly identify and manage these potential side effects.

4. A patient with schizophrenia is experiencing hallucinations. Which intervention is most appropriate?

• A. Encourage the patient to ignore the voices.
• B. Engage the patient in a reality-based activity.
• C. Provide a quiet environment to reduce stimulation.
• D. Ask the patient to describe the hallucinations in detail.

Correct answer: B

Rationale: Engaging the patient in a reality-based activity is the most appropriate intervention for a patient with schizophrenia experiencing hallucinations. This intervention can help distract the patient from the hallucinations and reorient them to the present, promoting a connection with reality and potentially reducing distress associated with the hallucinations. Choice A, encouraging the patient to ignore the voices, may not be effective as it can be challenging for the patient to dismiss the hallucinations. Choice C, providing a quiet environment, is helpful but may not directly address the hallucinations. Choice D, asking the patient to describe the hallucinations in detail, may increase the patient's focus on the hallucinations, potentially worsening distress.

5. At what point should the nurse determine that a client is at risk for developing a mental disorder?

• A. When thoughts, feelings, and behaviors are not reflective of the DSM-5 criteria
• B. When maladaptive responses to stress are coupled with interference in daily functioning
• C. When the client communicates significant distress
• D. When the client uses defense mechanisms as ego protection

Correct answer: B

Rationale: The nurse should determine that the client is at risk for mental disorder when responses to stress are maladaptive and interfere with daily functioning. The DSM-5 indicates that in order to be diagnosed with a mental disorder, there must be significant disturbance in cognition, emotion, regulation, or behavior that reflects a dysfunction in the psychological, biological or developmental processes underlying mental functioning. These disorders are usually associated with significant distress or disability in social, occupational, or other important activities. The client's ability to communicate distress would be considered a positive attribute.

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