Nursing Elites

1. A client who has agoraphobia (a fear of crowds) is starting desensitization therapy with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care?

• A. Encourage the substitution of positive thoughts for negative ones.
• B. Establish trust by providing a calm, safe environment.
• C. Gradually expose the client to larger crowds.
• D. Encourage deep breathing when anxiety escalates in a crowd.

Correct answer: B

Rationale: Establishing trust by providing a calm and safe environment is crucial for the success of desensitization therapy in clients with agoraphobia. This approach helps the client feel safe and secure, allowing them to gradually confront their fear of crowds. Encouraging positive thoughts (choice A) is beneficial but not as immediately critical as creating a safe space. Progressively exposing the client to larger crowds (choice C) should occur after trust is established and in a controlled manner. Encouraging deep breathing (choice D) is helpful, but creating a safe environment takes precedence to build a foundation for successful desensitization.

2. The nurse completes an assessment of a client who is experiencing intimate partner violence (IPV). Which finding of the injuries should the nurse include in the documentation?

• A. The client’s significant other’s statement.
• B. Photographs.
• C. General description.
• D. A summary of the client’s feelings.

Correct answer: B

Rationale: In cases of intimate partner violence (IPV), documenting injuries is essential for legal and medical purposes. Photographs provide concrete and objective evidence of the injuries, leaving no room for interpretation or doubt. This visual documentation can be crucial in legal proceedings and serve as a critical component in ensuring the safety and well-being of the client. The significant other's statement (Choice A) may not accurately reflect the client's injuries and could be biased. A general description (Choice C) lacks the specificity and objectivity that photographs offer. Summarizing the client's feelings (Choice D) is important for emotional support but does not provide the concrete evidence needed in documenting IPV cases.

3. An elderly client diagnosed with delirium is being treated with antipsychotic medication. Which side effect should the nurse monitor for in this client?

• A. Akathisia
• B. Hallucinations
• C. Orthostatic hypotension
• D. Drowsiness

Correct answer: C

Rationale: The correct side effect that the nurse should monitor for in an elderly client diagnosed with delirium and treated with antipsychotic medication is orthostatic hypotension. Antipsychotic medications can lead to a drop in blood pressure upon standing, particularly in elderly individuals. Akathisia (choice A) refers to a movement disorder characterized by a feeling of inner restlessness and a compelling need to be in constant motion, which can be a side effect of antipsychotic medications but is not specific to elderly clients with delirium. Hallucinations (choice B) are sensory perceptions that appear real but are created by the mind, and while they can be associated with certain conditions or medications, they are not a common side effect of antipsychotic medications in elderly clients with delirium. Drowsiness (choice D) is a general CNS depressant effect that can occur with antipsychotic medications but is not the specific side effect that the nurse should be monitoring for in this case.

4. The nurse is planning client teaching for a 35-year-old client with early alcoholic cirrhosis. Which self-care measure should the nurse emphasize for the client’s recovery?

• A. Support group meetings.
• B. Vitamin B and multivitamin supplements.
• C. Diet with adequate calories and protein.
• D. Alcohol abstinence.

Correct answer: D

Rationale: Alcohol abstinence is the most critical self-care measure for a client with early alcoholic cirrhosis. Continued alcohol consumption can lead to further liver damage and worsen the condition. Support group meetings may offer emotional support but do not address the root cause of the issue. While vitamin supplements and a nutritious diet are important for overall health, alcohol abstinence takes precedence in managing cirrhosis caused by alcohol consumption.

5. What assessment questions should the nurse ask when attempting to determine a teenager’s mental health resilience? Select all that apply.

• A. How did you cope when your father deployed with the Army for a year in Iraq?
• B. Who did you go to for advice while your father was away for a year in Iraq?
• C. How do you feel about talking to a mental health counselor?
• D. Where do you see yourself in 10 years?

Correct answer: C

Rationale: The question 'How do you feel about talking to a mental health counselor?' is the most appropriate to assess the teenager's mental health resilience as it directly addresses their willingness to seek help and cope effectively. Choices A and B focus on coping mechanisms during a specific event, which may not reflect the teenager's overall resilience. Choice D is more related to future aspirations rather than assessing current mental health resilience.

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