Nursing Elites

1. Which of the following is a symptom associated with sensory overload?

• A. Disorientation
• B. Drowsiness
• C. Emotional lability
• D. Depression

Correct answer: A

Rationale: Disorientation is a common symptom associated with sensory overload. When an individual experiences sensory overload, their brain may become overwhelmed with excessive information, leading to disorientation. This can manifest as an inability to concentrate, racing thoughts, and restless behavior. Sensory overload occurs when a person is unable to either control the amount of environmental stimuli they are exposed to or process the stimuli effectively. Drowsiness, emotional lability, and depression are not typical symptoms of sensory overload. Drowsiness may indicate fatigue or boredom, emotional lability refers to rapid and exaggerated changes in mood, and depression is a mood disorder characterized by persistent feelings of sadness and hopelessness.

2. A client is having difficulty applying for a job due to panic and anxiety. A nurse is helping by pretending to be the job supervisor while the client practices answering questions during an imaginary interview. This technique is an example of:

• A. Reinforcement
• B. Presenting reality
• C. Role playing
• D. Summarizing

Correct answer: C

Rationale: Role-playing is the correct answer. It involves practicing appropriate behaviors during imaginary scenarios that simulate real-life situations. In this scenario, the nurse is helping the client prepare for a job interview by acting as the job supervisor. Role-playing allows the client to practice and develop strategies to cope with anxiety and panic during the actual interview. Reinforcement (Choice A) involves providing consequences to strengthen a behavior. Presenting reality (Choice B) involves helping the client differentiate between real and unreal experiences. Summarizing (Choice D) involves condensing information. In this context, role-playing is the most appropriate technique to address the client's anxiety and panic related to job interviews.

3. A client had a first-trimester abortion and has been unable to function for 3 months. Which type of grief is the client experiencing?

• A. Complex bereavement
• B. Anticipatory
• C. Disenfranchised
• D. Complicated

Correct answer: C

Rationale: The client is experiencing disenfranchised grief. Disenfranchised grief refers to grief over a loss that is not socially recognized or acknowledged. In this case, grief after an abortion falls into this category. It can lead to prolonged emotional distress as the loss may not be openly acknowledged or supported by others. Complex bereavement is characterized by dysfunctional grieving that extends beyond 12 months. Anticipatory grief occurs when the loss is expected or predictable, allowing individuals to start the grieving process before the actual loss. Complicated grief is marked by an inability to progress through the grief stages, leading to intense feelings of depression, anger, and emptiness, often coupled with a preoccupation with the deceased.

4. Ten minutes after signing an operative permit for a fractured hip, an older client states, 'The aliens will be coming to get me soon!' and falls asleep. Which action should the nurse implement next?

• A. Make the client comfortable and allow the client to sleep.
• B. Assess the client's neurologic status.
• C. Notify the surgeon about the comment.
• D. Ask the client's family to co-sign the operative permit.

Correct answer: B

Rationale: The client's statement about aliens coming to get them could indicate confusion, which raises concerns about their neurologic status. Since informed consent for surgery requires the client to be mentally competent, the nurse should assess the client's neurologic status to ensure they understand and can legally provide consent. Option A of making the client comfortable and letting them sleep does not address the potential neurologic issue. If the nurse finds the client to be confused, it is essential to inform the surgeon and seek permission from the next of kin if necessary. Therefore, assessing the client's neurologic status is the priority to ensure the client's ability to consent to the surgery.

5. Which parental statement would the nurse recognize as the appropriate application of time-out when disciplining a 4-year-old?

• A. I send my child to their bedroom for misbehaving.
• B. We limit time-out to 4 minutes per incident.
• C. Putting my child in a dark closet for time-out is very effective.
• D. I explain the reason for the time-out before and after disciplining my child.

Correct answer: D

Rationale: The correct answer is to explain the reason for the time-out before and after disciplining the child. This approach reinforces the child's association of the time-out with the undesirable behavior, helping the child learn to control those behaviors. Sending a child to their bedroom may lead to negative associations with bedtime or be ineffective if the child enjoys spending time in their bedroom. Time-out should ideally be limited to 1 minute per year of age, so a time-out for a 4-year-old should be limited to 4 minutes. Placing a child in a dark closet can create fear and damage the child's trust in their parents as a source of safety, making it an inappropriate and harmful approach. Even if this method seems effective in the short term, the potential long-term consequences outweigh any immediate benefits.

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