Nursing Elites

1. Identify the type of 'trigger' with the correct 'trigger' that can possibly lead to disturbed behavior.

• A. Emotional: room coldness
• B. Environmental: boredom
• C. Physical: pain
• D. Communication: silence

Correct answer: C

Rationale: Physical pain is a common trigger that can lead to disturbed behavior in individuals, especially when they are unable to communicate their pain effectively. Choices A, B, and D are incorrect. Room coldness falls under environmental triggers, boredom is associated with emotional triggers, and silence is a communication aspect rather than a direct trigger for disturbed behavior.

2. While conducting an intake assessment of an adult male at a community mental health clinic, the nurse notes that his affect is flat, he responds to questions with short answers, and he reports problems with sleeping. He reports that his life partner recently died from pneumonia. Which action is most important for the nurse to implement?

• A. Encourage the client to see the clinic's grief counselor.
• B. Determine if the client has a family history of suicide attempts.
• C. Inquire about whether the life partner was suffering from AIDS.
• D. Consult with the health care provider about the client's need for antidepressant medications.

Correct answer: A

Rationale: The client is exhibiting normal grieving behaviors, so referral to a grief counselor is the most important intervention for the nurse to implement. Option B is relevant but is not a high-priority intervention compared to addressing the immediate grief support needs of the client. Option C is irrelevant at this time but might be important when determining the client's risk for contracting the illness. While antidepressant medication might be necessary based on further assessment, grief counseling is a more appropriate initial action as grief is a typical response to the loss of a loved one.

3. One week after being told that she has terminal cancer with a life expectancy of 3 weeks, a female client tells the nurse, 'I think I will plan a big party for all my friends.' How should the nurse respond?

• A. 'You may not have enough energy before long to hold a big party.'
• B. 'Do you mean to say that you want to plan your funeral and wake?'
• C. 'Planning a party and thinking about all your friends sounds like fun.'
• D. 'You should be thinking about spending your last days with your family.'

Correct answer: C

Rationale: Setting goals that bring pleasure is appropriate and should be encouraged by the nurse as long as the nurse does not perpetuate a client's denial. Option A is a negative response, implying that the client should not plan a party, which is not supportive. Option B is presumptive and may not reflect the client's true intentions. The correct response (Option C) acknowledges the client's positive plans and encourages her to enjoy her time with friends. Option D, while family is important, does not consider the client's wishes and choices, which should be respected and supported in this situation.

4. A client who has been on hemodialysis for 2 years communicates in an angry, critical manner and does not adhere to the prescribed medications and diet. Which explanation for the client's behavior would be useful to consider in planning care?

• A. An attempt to punish the nursing staff
• B. A constructive method of accepting reality
• C. A defense against underlying depression and fear
• D. An effort to maintain life and to live it as fully as possible

Correct answer: C

Rationale: The client's angry, critical communication and non-adherence to treatment suggest underlying emotional struggles. The behavior is likely a defense mechanism against feelings of depression and fear. It is essential to consider that the client's actions are not intentionally aimed at punishing others but rather a manifestation of internal distress. Option A is incorrect as the behavior is not about punishing the nursing staff. Option B is incorrect because the behavior is not a constructive way of accepting reality but rather a maladaptive coping mechanism. Option D is incorrect as the behavior is not primarily driven by an effort to maintain life but rather by emotional distress.

5. Which of the following is a typical assessment finding of a 24-year-old female with anorexia nervosa?

• A. Weight loss of more than 2% body fat
• B. Frequent binge-eating episodes followed by induced vomiting
• C. A history of poor academic performance and mediocre achievements
• D. Lack of menstruation

Correct answer: D

Rationale: The correct answer is D: Lack of menstruation. Amenorrhea, or lack of menstruation, is a common occurrence in individuals with anorexia nervosa. The induced starvation from anorexia can disrupt hormone levels, leading to menstrual irregularities. This hormonal imbalance can result in amenorrhea, which can have long-term consequences such as osteoporosis and infertility. Choices A, B, and C are incorrect. Weight loss of more than 2% body fat may be a consequence of anorexia but is not a specific assessment finding. Frequent binge-eating episodes followed by induced vomiting are more characteristic of bulimia nervosa, not anorexia nervosa. A history of poor academic performance and mediocre achievements is not a typical assessment finding related to anorexia nervosa symptoms.

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