Nursing Elites

1. A 45-year-old female client is admitted to the psychiatric unit for evaluation. Her husband states that she has been reluctant to leave home for the last six months. The client has not gone to work for a month and has been terminated from her job. She has not left the house since that time. This client is displaying symptoms of which disorder?

• A. Claustrophobia.
• B. Acrophobia.
• C. Agoraphobia.
• D. Necrophobia.

Correct answer: C

Rationale: The correct answer is C, Agoraphobia. Agoraphobia involves the fear of situations where escape might be difficult, often leading to the individual avoiding public spaces or leaving their home. In this case, the client's reluctance to leave home, not going to work, and staying indoors for an extended period align with the symptoms of agoraphobia. Choices A, B, and D are incorrect. Claustrophobia is the fear of confined spaces, acrophobia is the fear of heights, and necrophobia is the fear of death or dead things, none of which are consistent with the client's symptoms described in the scenario.

2. A 40-year-old male client diagnosed with schizophrenia and alcohol dependence has not had any visitors or phone calls since admission. He reports he has no family that cares about him and was living on the streets prior to this admission. According to Erikson's theory of psychosocial development, which stage is the client in at this time?

• A. Isolation.
• B. Stagnation.
• C. Despair.
• D. Role confusion.

Correct answer: B

Rationale: The client is in Erikson's 'Generativity vs. Stagnation' stage (age 24 to 45). This stage involves maintaining intimate relationships and moving toward developing a family, which the client seems to be struggling with due to lack of visitors and family support. Choices (A), (C), and (D) are incorrect. Isolation typically occurs in young adulthood (age 18 to 25), Despair in maturity (age 45 to death), and Role confusion in adolescence (age 12 to 20). These stages reflect challenges individuals face if they do not successfully navigate their psychosocial developmental tasks.

3. The nurse suspects child abuse when assessing a 3-year-old boy and noticing several small, round burns on his legs and trunk that might be the result of cigarette burns. Which parental behavior provides the greatest validation for such suspicions?

• A. The parents' explanation of how the burns occurred is different from the child's explanation of how they occurred.
• B. The parents seem to dismiss the severity of the child's burns, saying they are very small and have not posed any problem.
• C. The parents become very anxious when the nurse suggests that the child may need to be admitted for further evaluation.
• D. The parents tell the nurse that the child was burned in a house fire which is incompatible with the nurse's observation of the type of burn.

Correct answer: D

Rationale: (D) provides the most validation for suspecting child abuse. The parent's explanation (subjective data) that the child was burned in a house fire is incompatible with the objective data observed by the nurse (small, round burns on the legs and trunk). (A) relies on subjective data, and the child's explanation might not accurately reflect the situation due to various factors like age or fear. The apparent lack of concern from the parents (B) is inconclusive as the nurse's interpretation of their reaction could be subjective. While parental anxiety (C) could hint at potential child abuse, it's important to note that most parents would naturally be anxious about their child's hospitalization, making it a less definitive indicator compared to the inconsistency in the explanation provided by the parents in option (D).

4. An LPN/LVN is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented that the client is experiencing anxiety as a result of a situational crisis. The nurse determines that this type of crisis is caused by:

• A. Witnessing a murder
• B. The death of a loved one
• C. A fire that destroyed the client's home
• D. A recent rape episode experienced by the client

Correct answer: B

Rationale: The correct answer is B: 'The death of a loved one.' A situational crisis, like the death of a loved one, can lead to anxiety due to a significant change or loss in the person's life. Choices A, C, and D involve traumatic events, but a situational crisis typically refers to life events that disrupt an individual's normal pattern of living, such as the death of a loved one.

5. A nurse is caring for a client who is experiencing severe anxiety. Which intervention is most appropriate for the nurse to implement?

• A. Instruct the client to take deep breaths and focus on the present.
• B. Encourage the client to discuss their fears in detail.
• C. Distract the client with a humorous story or anecdote.
• D. Leave the client alone to process their emotions.

Correct answer: A

Rationale: The correct intervention for a client experiencing severe anxiety is to instruct the client to take deep breaths and focus on the present. Deep breathing can help reduce the physiological symptoms of anxiety and provide the client with a way to regain control over their emotions. Choice B is incorrect as discussing fears in detail may escalate anxiety levels. Choice C is inappropriate as distracting the client may not address the root cause of anxiety. Choice D is not recommended as leaving the client alone can increase feelings of isolation and distress.

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