Nursing Elites

1. A client diagnosed with generalized anxiety disorder (GAD) states, 'I just can't stop worrying about everything.' Which nursing diagnosis is most appropriate for this client?

• A. Ineffective coping
• B. Disturbed thought processes
• C. Chronic low self-esteem
• D. Social isolation

Correct answer: A

Rationale: The most appropriate nursing diagnosis for a client with generalized anxiety disorder (GAD) who expresses an inability to stop worrying about everything is 'Ineffective coping.' This diagnosis indicates the client's struggle to manage anxiety and worry effectively, which aligns with the client's statement. 'Disturbed thought processes' (Choice B) would involve disorganized or irrational thinking patterns, which are not directly related to the client's statement about excessive worry. 'Chronic low self-esteem' (Choice C) refers to a long-standing negative self-evaluation and is not the most fitting diagnosis for the client's current concern. 'Social isolation' (Choice D) pertains to a lack of social interactions and support, which is not the primary issue highlighted by the client's statement.

2. When explaining suicide precautions to a client, what would be the best explanation?

• A. You need to control yourself. If you cannot, we will do it for you.
• B. This can seem embarrassing, but we want you to be safe.
• C. You will stay on these precautions for one week.
• D. When you feel you are safer, then we will not need to observe you.

Correct answer: D

Rationale: Choice D provides a supportive and empowering explanation to the client on suicide precautions. It emphasizes the client's own sense of safety and control, indicating that the observation is temporary and can be removed when the client feels safer. This approach promotes autonomy and encourages the client to actively participate in their own well-being, fostering a therapeutic relationship based on trust and collaboration.

3. A healthcare provider is providing care for a patient with major depressive disorder who is prescribed a tricyclic antidepressant (TCA). Which common side effect should the healthcare provider educate the patient about?

• A. Hypertension
• B. Diarrhea
• C. Dry mouth
• D. Weight loss

Correct answer: C

Rationale: Dry mouth is a common side effect associated with tricyclic antidepressants (TCAs). TCAs can cause anticholinergic side effects, such as dry mouth, due to their mechanism of action. Educating the patient about dry mouth can help them stay informed and manage this common side effect effectively during treatment. Hypertension (Choice A) is not a common side effect of TCAs. Diarrhea (Choice B) is more commonly associated with selective serotonin reuptake inhibitors (SSRIs) than with TCAs. Weight loss (Choice D) is not a common side effect of TCAs; in fact, TCAs are more likely to cause weight gain.

4. A teenage boy is attracted to a female teacher. Without objective evidence, a school nurse overhears the boy state, 'I know she wants me.' This statement reflects which defense mechanism?

• A. Displacement
• B. Projection
• C. Rationalization
• D. Sublimation

Correct answer: B

Rationale: The correct answer is B: Projection. The nurse should determine that the client's statement reflects the defense mechanism of projection. Projection involves attributing one's unacceptable feelings or impulses to another person. By projecting these feelings onto someone else, the individual reduces their own anxiety. Displacement involves transferring feelings from one target to another, not attributing them to another person. Rationalization involves making excuses to justify behavior, not attributing feelings to others. Sublimation involves channeling unacceptable drives or impulses into more constructive and acceptable activities, not attributing feelings to another person.

5. Which of the following is a common side effect of selective serotonin reuptake inhibitors (SSRIs)?

• A. Hypotension
• B. Sexual dysfunction
• C. Increased appetite
• D. Tachycardia

Correct answer: B

Rationale: Corrected Rationale: Sexual dysfunction is a commonly reported side effect of selective serotonin reuptake inhibitors (SSRIs). SSRIs can affect sexual function by causing issues such as decreased libido, delayed ejaculation, erectile dysfunction, or anorgasmia. Patients should be educated about these potential side effects when starting SSRIs to facilitate informed decision-making and appropriate management strategies. Incorrect Choices: A) Hypotension is not a common side effect of SSRIs. C) Increased appetite is not a common side effect of SSRIs. D) Tachycardia is not a common side effect of SSRIs.

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