Nursing Elites

1. Which individual is likely experiencing symptoms of derealization?

• A. I just feel like I’m looking at life through a fog and that can’t be my face in the mirror.
• B. I cannot recall why I’m living in this town or how I got here.
• C. There are just too many people living in my head now.
• D. I feel like I’m going to die, I’m having a heart attack.

Correct answer: A

Rationale: The individual describing feeling like they are looking at life through a fog and questioning their reflection in the mirror is likely experiencing symptoms of derealization. Derealization involves feelings of detachment from one's surroundings, which can manifest as a sense of unreality or distortion of the environment. Choice B describes dissociative amnesia, which involves memory loss related to personal information or traumatic events. Choice C suggests dissociative identity disorder (DID), where a person experiences two or more distinct identities or personality states. Choice D indicates symptoms of a panic attack, such as fearing imminent death and physical sensations like a heart attack.

2. A healthcare professional is assessing a patient with bipolar disorder. Which finding suggests the patient is experiencing a manic episode?

• A. Decreased need for sleep
• B. Feelings of worthlessness
• C. Increased need for sleep
• D. Avoidance of social interactions

Correct answer: A

Rationale: During a manic episode in patients with bipolar disorder, they often experience a decreased need for sleep. This symptom is characterized by feeling rested after only a few hours of sleep, or even feeling like they can go without sleep for extended periods without feeling tired. The increased energy levels and racing thoughts during a manic episode contribute to the decreased need for sleep.

3. A patient is being assessed for generalized anxiety disorder (GAD). Which symptom is the patient most likely to report?

• A. Excessive worrying about various aspects of life.
• B. Extreme mood swings between euphoria and depression.
• C. Persistent thoughts of self-harm.
• D. Hearing voices that others do not hear.

Correct answer: A

Rationale: Patients with generalized anxiety disorder (GAD) commonly present with excessive worrying about various aspects of life. This persistent and uncontrollable worry is a hallmark symptom of GAD and can significantly impact daily functioning and quality of life. Extreme mood swings (choice B), persistent thoughts of self-harm (choice C), and auditory hallucinations (choice D) are more indicative of other mental health conditions like bipolar disorder, depression, and schizophrenia, respectively. These symptoms are not specific to GAD.

4. A patient with obsessive-compulsive disorder (OCD) frequently washes their hands. Which nursing intervention is most appropriate?

• A. Allow the patient to wash their hands, then gradually limit the time spent on this behavior.
• B. Discourage the patient from discussing their obsessions.
• C. Encourage the patient to suppress their compulsive behaviors.
• D. Avoid setting limits on the patient's compulsive behaviors.

Correct answer: A

Rationale: In managing a patient with OCD who frequently washes their hands, it is important to understand that compulsive behaviors provide temporary relief from anxiety. Allowing the patient to engage in their rituals initially and then gradually setting limits on the time spent can help them gain control over their compulsions. This approach supports the patient without causing undue distress, ultimately assisting in managing OCD symptoms effectively. Choice B is incorrect as discouraging the patient from discussing their obsessions can hinder therapeutic communication and understanding of their condition. Choice C is wrong because encouraging the patient to suppress their compulsive behaviors may increase their anxiety and lead to worsening symptoms. Choice D is also incorrect as avoiding setting limits on the patient's compulsive behaviors does not help the patient in gaining control over their OCD symptoms.

5. What is the most appropriate nursing diagnosis for a patient with agoraphobia who reports not having left their house in months?

• A. Social isolation
• B. Ineffective coping
• C. Risk for injury
• D. Impaired social interaction

Correct answer: A

Rationale: The nursing diagnosis 'Social isolation' is most appropriate for a patient with agoraphobia who has not left their house in months. Agoraphobia often leads to the avoidance of situations or places perceived as unsafe, resulting in social isolation. This diagnosis reflects the patient's limited social interactions and confinement to the home environment, which can impact their overall well-being and mental health. The other options are not as relevant in this scenario: 'Ineffective coping' does not directly address the social withdrawal aspect, 'Risk for injury' is not the primary concern presented, and 'Impaired social interaction' does not capture the extent of isolation described.

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