Nursing Elites

1. A client is diagnosed with schizophrenia and exhibits apathy, lack of energy, and lack of interest in daily activities. The nurse should recognize that these symptoms are most likely due to which of the following?

• A. Negative symptoms of schizophrenia.
• B. Positive symptoms of schizophrenia.
• C. Side effects of antipsychotic medication.
• D. Symptoms of depression.

Correct answer: A

Rationale: Apathy, lack of energy, and lack of interest in daily activities are negative symptoms of schizophrenia (A). Positive symptoms of schizophrenia include hallucinations and delusions (B). While antipsychotic medication side effects can sometimes cause lethargy or sedation (C), the scenario specifically describes negative symptoms. Depression can also cause similar symptoms (D), but in the context of schizophrenia, these are recognized as negative symptoms.

2. A 38-year-old female client is admitted with a diagnosis of paranoid schizophrenia. When her tray is brought to her, she refuses to eat and tells the nurse, 'I know you are trying to poison me with that food.' Which response would be most appropriate for the nurse to make?

• A. 'I'll leave your tray here. I am available if you need anything else.'
• B. 'You're not being poisoned. Why do you think someone is trying to poison you?'
• C. 'No one on this unit has ever died from poisoning. You're safe here.'
• D. 'I will talk to your healthcare provider about the possibility of changing your diet.'

Correct answer: A

Rationale: Choice (A) offers support without confrontation, allowing the client to feel safe and respected. Choices (B) and (C) directly challenge the client's delusion, which can increase anxiety and distrust. Choice (D) focuses on a non-essential issue and does not address the client's immediate emotional needs.

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. What is the most important goal of care for a client diagnosed with generalized anxiety disorder (GAD) who has been taking the benzodiazepine alprazolam (Xanax) long-term? The client will:

• A. Describe a decrease in anxiety using a 1 to 10 anxiety scale.
• B. State the importance of not abruptly stopping the medication.
• C. Not experience dizziness, lightheadedness, or sedation.
• D. Attend scheduled individual and group therapy sessions.

Correct answer: B

Rationale: The correct answer is B. The most important goal of care for a client with generalized anxiety disorder (GAD) taking alprazolam long-term is to ensure they understand the importance of not abruptly stopping the medication. Abruptly stopping benzodiazepines can lead to withdrawal symptoms and potential complications. Choice A is not the most critical goal as the focus should be on the safe continuation of the medication. Choice C is important but not as crucial as preventing abrupt discontinuation. Choice D is beneficial for overall treatment but not the most important goal in this scenario.

5. A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. What action should the nurse implement?

• A. Attempt to ask the client simple questions.
• B. Postpone the client interview until the next day.
• C. Ask another nurse to talk with the client.
• D. Document the client's paranoid behavior.

Correct answer: A

Rationale: When a client is guarded, suspicious, and resistant to talking, it is important for the nurse to attempt to ask the client simple questions. Simple questions can help build rapport, establish trust, and create a non-threatening environment. This approach may ease the client into more detailed discussions while reducing feelings of suspicion. Postponing the interview may increase the client's anxiety and distrust, while asking another nurse to talk with the client may disrupt continuity of care and the establishment of a therapeutic relationship. Documenting the client's behavior is important for the client's medical record, but it should not be the first action taken in this situation.

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