Nursing Elites

1. A client who is admitted to the mental health unit reports shortness of breath and dizziness. The client tells the nurse, “I feel like I’m going to die.” Which nursing problem should the nurse include in this client’s plan of care?

• A. Mood disturbance
• B. Moderate anxiety
• C. Altered thoughts
• D. Social isolation

Correct answer: B

Rationale: The correct answer is B: Moderate anxiety. When a client presents with symptoms such as shortness of breath, dizziness, and a fear of dying, it indicates moderate anxiety. Anxiety can manifest physically with symptoms like these. Mood disturbance (choice A) refers to a change in mood, while altered thoughts (choice C) relate to cognitive changes. Social isolation (choice D) involves a lack of social interaction, which is not the primary concern in this scenario where the client is experiencing acute anxiety symptoms.

2. During an annual physical at the corporate clinic, a male employee expresses to the RN that his high-stress job is causing trouble in his personal life. He mentions getting so angry while driving to and from work that he has considered 'getting even' with other drivers. How should the RN respond?

• A. “Anger is contagious and could lead to major confrontations.”
• B. “Try not to let your anger cause you to act impulsively.”
• C. “Expressing your anger to a stranger could lead to an unsafe situation.”
• D. “It seems like there are many situations that make you feel angry.”

Correct answer: B

Rationale: The correct response for the RN is to advise the employee not to act impulsively when feeling angry. This approach helps the individual learn to manage anger in a constructive manner, reducing the likelihood of potential conflicts. Choice A is incorrect because although acknowledging that anger can escalate into confrontations is valid, it does not provide immediate guidance on managing the anger. Choice C focuses on the dangers of expressing anger to strangers but does not address the core issue of managing anger. Choice D simply acknowledges the employee's feelings without providing guidance on how to address the situation effectively.

3. An adolescent with anorexia nervosa is undergoing nutritional therapy. Which finding best indicates that the client is making progress in treatment?

• A. Client gains 2 pounds in a week.
• B. Client describes a positive body image.
• C. Client engages in recreational activities.
• D. Client begins to talk about future goals.

Correct answer: A

Rationale: The correct answer is A. Weight gain is a crucial indicator of progress in the treatment of anorexia nervosa. In individuals with anorexia, restoring and maintaining a healthy weight is a primary goal to address the underlying nutritional deficiencies and health complications associated with the disorder. While choices B, C, and D are positive developments in the client's overall well-being and recovery journey, they are not as directly linked to the core issue of nutritional rehabilitation in anorexia nervosa. Describing a positive body image, engaging in recreational activities, and talking about future goals are important aspects of psychological and emotional recovery, but weight gain is a more immediate and objective measure of progress in treating anorexia nervosa.

4. A client with borderline personality disorder is admitted to the psychiatric unit. Which behavior should the nurse prioritize in the care plan?

• A. Self-harming behavior.
• B. Difficulty with interpersonal relationships.
• C. Impulsive spending and substance abuse.
• D. Inconsistent adherence to the treatment regimen.

Correct answer: A

Rationale: Self-harming behavior is the priority in the care plan for a client with borderline personality disorder. This behavior poses an immediate risk to the client's safety and requires prompt intervention. Difficulty with interpersonal relationships, impulsive spending, and substance abuse are also common in borderline personality disorder; however, self-harming behavior takes precedence due to its potential for severe harm. Inconsistent adherence to the treatment regimen, though important, is not as urgent as addressing the immediate safety concerns related to self-harm.

5. When developing a plan of care for a client admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing problem has the highest priority?

• A. Impaired comfort.
• B. Risk for injury.
• C. Ineffective breathing pattern.
• D. Ineffective coping.

Correct answer: C

Rationale: Ineffective breathing pattern is the highest priority nursing problem in this scenario because aspiration of a caustic material can lead to serious airway and respiratory issues. This poses an immediate threat to the client's life and requires urgent intervention to ensure adequate oxygenation and ventilation. The other options, such as Impaired comfort, Risk for injury, and Ineffective coping, are important but are secondary concerns compared to the critical nature of respiratory compromise in this situation.

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