Nursing Elites

1. A client diagnosed with paranoid schizophrenia states, 'The FBI is watching me. I see their agents everywhere.' Which is the nurse's most appropriate response?

• A. You shouldn't worry about that. It's not real.
• B. I don't see any FBI agents, but it sounds like you're feeling frightened.
• C. Let's talk about something else to take your mind off of it.
• D. Why do you think the FBI is watching you?

Correct answer: B

Rationale: Validating the client's feelings without reinforcing the delusion is important. This response acknowledges the client's fear without agreeing with the delusion. It shows empathy and understanding towards the client's emotions while not validating the delusional belief.

2. A healthcare professional is assessing a client with bipolar disorder who is experiencing a depressive episode. Which of the following findings should the healthcare professional expect? Select one that does not apply.

• A. High energy
• B. Feelings of hopelessness
• C. Insomnia or hypersomnia
• D. Decreased appetite

Correct answer: A

Rationale: During a depressive episode in bipolar disorder, clients typically exhibit low energy levels, feelings of hopelessness, insomnia or hypersomnia, and decreased appetite. High energy levels are more commonly seen in manic episodes of bipolar disorder.

3. A client has been diagnosed with post-traumatic stress disorder (PTSD). Which intervention should the nurse implement to reduce the client's anxiety?

• A. Encourage the client to avoid discussing the traumatic event.
• B. Encourage the client to participate in group therapy sessions.
• C. Encourage the client to engage in relaxation techniques.
• D. Encourage the client to maintain a daily journal.

Correct answer: C

Rationale: Engaging in relaxation techniques, such as deep breathing, mindfulness, or progressive muscle relaxation, can help reduce anxiety for clients with PTSD. These techniques promote relaxation and help manage stress responses, contributing to a sense of calmness and improved coping mechanisms in dealing with anxiety triggers associated with PTSD. Avoiding discussing the traumatic event (Choice A) may hinder the client's progress in processing and coping with the trauma. While group therapy (Choice B) can be beneficial, relaxation techniques are more specific for reducing anxiety in this context. Maintaining a daily journal (Choice D) may be helpful for some clients but might not directly address anxiety reduction as effectively as relaxation techniques.

4. A client is being assessed by a nurse after being diagnosed with anorexia nervosa. Which of the following findings should the nurse expect?

• A. Weight gain and increased appetite
• B. Lanugo on the face and back
• C. Increased body temperature and tachycardia
• D. Hyperactivity and distractibility

Correct answer: B

Rationale: In anorexia nervosa, individuals often develop lanugo, fine soft hair, on the face and back. This is a physiological response to the body's attempt to conserve heat due to a lack of subcutaneous fat. It is a common physical finding in clients with anorexia nervosa and can be a sign of severe malnutrition. Choices A, C, and D are incorrect because weight gain and increased appetite, increased body temperature and tachycardia, and hyperactivity and distractibility are not typically associated with anorexia nervosa. In fact, weight loss, decreased appetite, hypothermia, and bradycardia are more commonly seen in individuals with anorexia nervosa.

5. A client with obsessive-compulsive disorder (OCD) spends several hours each day washing her hands. Which intervention should the nurse implement?

• A. Encourage the client to wash her hands less frequently.
• B. Set a time limit for hand washing.
• C. Teach the client relaxation techniques.
• D. Discourage the client from washing her hands.

Correct answer: B

Rationale: Setting a time limit for hand washing is an appropriate intervention for a client with OCD who spends excessive time on this compulsive behavior. By setting a time limit, the nurse can help the client gradually reduce the compulsive behavior, promoting a more manageable approach to hand washing without completely discouraging it. Encouraging the client to wash her hands less frequently (Choice A) may not address the root of the issue and could lead to increased anxiety. Teaching relaxation techniques (Choice C) may be helpful for overall anxiety management but may not directly address the excessive hand washing behavior. Discouraging the client from washing her hands (Choice D) may increase anxiety and resistance, making it a less effective intervention.

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