Nursing Elites

1. A client is experiencing a moderate level of anxiety. Which is an example of an appropriate nursing intervention?

• A. Allow the client to pace in a safe environment.
• B. Encourage the client to discuss feelings.
• C. Help the client identify the cause of anxiety.
• D. Provide a distraction for the client.

Correct answer: A

Rationale: Allowing the client to pace in a safe environment is an appropriate nursing intervention for managing moderate anxiety levels. Allowing pacing provides the client with a physical outlet for their anxiety and can help them release nervous energy without increasing distress. It promotes movement and can aid in reducing feelings of restlessness or agitation. Encouraging the client to discuss feelings (Choice B) is more suitable for addressing emotional aspects of anxiety rather than providing an immediate physical outlet. Helping the client identify the cause of anxiety (Choice C) may be more appropriate for long-term management but may not address the immediate need for physical release. Providing a distraction (Choice D) may not directly address the physical needs associated with moderate anxiety levels.

2. A healthcare professional is assessing a client diagnosed with anorexia nervosa. Which of the following findings shouldn't the professional expect?

• A. Amenorrhea
• B. Lanugo
• C. Hypotension
• D. Hyperkalemia

Correct answer: D

Rationale: When assessing a client diagnosed with anorexia nervosa, healthcare professionals should expect findings such as amenorrhea, lanugo, hypotension, and bradycardia. Hyperkalemia is not typically associated with anorexia nervosa; instead, hypokalemia, which is low potassium levels, is more commonly seen in these individuals due to malnutrition and other factors.

3. What intervention should the nurse implement for a client with obsessive-compulsive disorder (OCD) performing ritualistic handwashing?

• A. Allow the client to continue the ritualistic behavior initially
• B. Immediately stop the client from performing the ritual
• C. Encourage the client to perform the ritual more quickly
• D. Provide a distraction to interrupt the ritual

Correct answer: A

Rationale: For a client with OCD performing ritualistic handwashing, the nurse should initially allow the client to continue the behavior. Abruptly stopping the behavior or providing a distraction can heighten the client's anxiety. Encouraging the client to perform the ritual more quickly does not address the underlying issue of OCD and may exacerbate their anxiety. Providing a distraction to interrupt the ritual may not be effective in the long term and could lead to increased distress. Gradual limits should be established over time to help the client manage and reduce the ritualistic behavior effectively.

4. A client diagnosed with schizophrenia is prescribed an antipsychotic medication. Which of the following side effects should the nurse not monitor for? Select all that apply.

• A. Tardive dyskinesia
• B. Neuroleptic malignant syndrome
• C. Orthostatic hypotension
• D. Hyperglycemia

Correct answer: A

Rationale: The nurse should not monitor for tardive dyskinesia as it is a potential long-term side effect of antipsychotic medications. However, the nurse should monitor for neuroleptic malignant syndrome, orthostatic hypotension, and hyperglycemia as these are common side effects associated with antipsychotic medications. Tardive dyskinesia is characterized by involuntary movements of the face, tongue, and extremities and may develop after prolonged use of antipsychotic drugs.

5. A patient with major depressive disorder is started on venlafaxine. Which class of antidepressant does this medication belong to?

• A. Selective serotonin reuptake inhibitors (SSRIs)
• B. Tricyclic antidepressants (TCAs)
• C. Monoamine oxidase inhibitors (MAOIs)
• D. Serotonin-norepinephrine reuptake inhibitors (SNRIs)

Correct answer: D

Rationale: Venlafaxine is classified as a serotonin-norepinephrine reuptake inhibitor (SNRI). SNRIs work by increasing the levels of both serotonin and norepinephrine in the brain, which helps alleviate symptoms of depression. This mechanism of action distinguishes SNRIs from other classes of antidepressants like SSRIs, TCAs, and MAOIs, making venlafaxine an effective choice for patients with major depressive disorder. Therefore, the correct answer is D. Choice A, SSRIs, primarily target serotonin reuptake only. Choice B, TCAs, work by inhibiting the reuptake of norepinephrine and serotonin, but they are not as selective as SNRIs. Choice C, MAOIs, inhibit the enzyme monoamine oxidase, leading to increased levels of various neurotransmitters, including serotonin and norepinephrine, but they are typically used as second- or third-line agents due to dietary restrictions and potential side effects.

Similar Questions