Nursing Elites

1. 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.

2. For a patient diagnosed with borderline personality disorder exhibiting self-harming behavior, which therapeutic approach is most appropriate?

• A. Dialectical behavior therapy
• B. Psychoanalysis
• C. Supportive therapy
• D. Pharmacotherapy

Correct answer: A

Rationale: The most appropriate therapeutic approach for a patient diagnosed with borderline personality disorder exhibiting self-harming behavior is dialectical behavior therapy (DBT). DBT is specifically designed to address the core symptoms of borderline personality disorder, including self-harming behaviors. It focuses on teaching patients skills to manage emotions, improve interpersonal relationships, and enhance distress tolerance. Psychoanalysis (Choice B) is not the most appropriate for immediate symptom management in this case. Supportive therapy (Choice C) may not provide the structured approach needed to address self-harming behaviors effectively. Pharmacotherapy (Choice D) may be used as an adjunct in some cases, but DBT is the frontline therapy for managing self-harming behaviors in borderline personality disorder.

3. Which of the following interventions is inappropriate for a client experiencing a panic attack?

• A. Provide a well-lit environment.
• B. Encourage deep breathing.
• C. Move the client to a quiet environment.
• D. Administer prescribed antianxiety medication.

Correct answer: A

Rationale: During a panic attack, a well-lit environment might exacerbate the client's symptoms due to sensory overload. Therefore, it is inappropriate to provide a well-lit environment during a panic attack. Encouraging deep breathing, moving the client to a quiet environment, and administering prescribed antianxiety medication are appropriate interventions for managing a panic attack. These actions help create a calming atmosphere and address the physiological symptoms associated with panic attacks.

4. The healthcare provider is providing medication education to a patient who has been prescribed lithium to stabilize mood. Which early signs and symptoms of toxicity should the healthcare provider stress to the patient? Select one that does not apply.

• A. Increased attentiveness
• B. Getting up at night to urinate
• C. Improved vision
• D. An upset stomach for no apparent reason

Correct answer: C

Rationale: Early signs of lithium toxicity include gastrointestinal upset, tremors, increased urination, and increased thirst. Improved vision is not a typical early sign of lithium toxicity and should be ruled out as a symptom to watch for.

5. A patient with major depressive disorder is prescribed a selective serotonin reuptake inhibitor (SSRI). The nurse should educate the patient about which potential side effect?

• A. Hypertension
• B. Diarrhea
• C. Sexual dysfunction
• D. Weight gain

Correct answer: C

Rationale: Corrected Rationale: Selective serotonin reuptake inhibitors (SSRIs) are commonly associated with sexual dysfunction as a side effect. This adverse effect includes decreased libido, delayed orgasm, and erectile dysfunction. Educating patients about this potential side effect is crucial to manage expectations and consider appropriate interventions. Choices A, B, and D are incorrect as SSRIs are not typically associated with hypertension, diarrhea, or weight gain as common side effects.

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