Nursing Elites

1. When attempting to determine a teenager's mental health resilience, what assessment question should the nurse ask that is not applicable?

• A. How did you cope when your father deployed with the Army for a year in Iraq?
• B. Who did you go to for advice while your father was away for a year in Iraq?
• C. How do you feel about talking to a mental health counselor?
• D. Why would you think that is a better option than meeting with me?

Correct answer: D

Rationale: Assessing a teenager's mental health resilience involves exploring coping mechanisms, support systems, and attitudes towards seeking help. Option D is not relevant to assessing resilience but rather focuses on the comparison between seeking advice from a counselor versus the nurse, which doesn't directly gauge the teenager's resilience.

2. A nurse is providing education to the family of a client who has been diagnosed with major depressive disorder. Which of the following instructions should the nurse include?

• A. Encourage the client to avoid caffeine.
• B. Encourage the client to participate in physical activity.
• C. Encourage the client to express their feelings.
• D. Encourage the client to avoid isolation.

Correct answer: D

Rationale: The nurse should instruct the family to encourage the client to avoid isolation. Social support and interaction are crucial for individuals with major depressive disorder as it can help in improving mood, reducing feelings of loneliness, and providing a sense of belonging and support. Choices A, B, and C are not the most appropriate instructions for a client with major depressive disorder. While avoiding caffeine can be beneficial for some individuals with anxiety or sleep issues, it is not a primary intervention for major depressive disorder. Encouraging physical activity and expressing feelings are important aspects of managing depression, but avoiding isolation is more critical to address first.

3. A healthcare professional is assessing a client diagnosed with anorexia nervosa. Which of the following findings shouldn't the professional expect?

• A. Amenorrhea
• B. Lanugo
• C. Hypotension
• D. Hyperkalemia

Correct answer: D

Rationale: When assessing a client diagnosed with anorexia nervosa, healthcare professionals should expect findings such as amenorrhea, lanugo, hypotension, and bradycardia. Hyperkalemia is not typically associated with anorexia nervosa; instead, hypokalemia, which is low potassium levels, is more commonly seen in these individuals due to malnutrition and other factors.

4. 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.

5. A client with borderline personality disorder is admitted to the psychiatric unit. Which intervention should the nurse implement to promote the client's safety?

• A. Implement a no-harm contract with the client.
• B. Monitor the client closely for signs of self-harm.
• C. Encourage the client to participate in recreational activities.
• D. Encourage the client to maintain a structured daily routine.

Correct answer: A

Rationale: When a client with borderline personality disorder is admitted to a psychiatric unit, implementing a no-harm contract is a crucial intervention to promote the client's safety. A no-harm contract is a formal agreement between the client and the healthcare provider stating that the client commits to not harm themselves or others. This intervention helps in establishing boundaries and promoting safety by enhancing communication and accountability between the client and the healthcare team. Monitoring the client closely for signs of self-harm (Choice B) is important but does not directly address promoting safety through a formal agreement. Encouraging participation in recreational activities (Choice C) and maintaining a structured daily routine (Choice D) are beneficial interventions but may not directly address the immediate safety concerns of a client with borderline personality disorder.

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