Nursing Elites

1. A client with a history of alcohol use disorder is admitted to the hospital for detoxification. Which of the following symptoms shouldn't the nurse expect to observe during withdrawal?

• A. Tremors
• B. Hallucinations
• C. Diaphoresis
• D. Bradycardia

Correct answer: D

Rationale: During alcohol withdrawal, the nurse should expect to observe symptoms such as tremors, hallucinations, and diaphoresis. Seizures may also occur during severe withdrawal. Bradycardia is not typically associated with alcohol withdrawal; instead, tachycardia (an increased heart rate) is more commonly observed due to the stimulant effects of alcohol withdrawal on the sympathetic nervous system.

2. A patient with major depressive disorder is prescribed a selective serotonin reuptake inhibitor (SSRI). The nurse should educate the patient about which potential side effect?

• A. Hypertension
• B. Diarrhea
• C. Sexual dysfunction
• D. Weight gain

Correct answer: C

Rationale: Corrected Rationale: Selective serotonin reuptake inhibitors (SSRIs) are commonly associated with sexual dysfunction as a side effect. This adverse effect includes decreased libido, delayed orgasm, and erectile dysfunction. Educating patients about this potential side effect is crucial to manage expectations and consider appropriate interventions. Choices A, B, and D are incorrect as SSRIs are not typically associated with hypertension, diarrhea, or weight gain as common side effects.

3. Which neurotransmitter is primarily implicated in the development of schizophrenia?

• A. Serotonin
• B. Norepinephrine
• C. Dopamine
• D. Acetylcholine

Correct answer: C

Rationale: The correct answer is dopamine. Dopamine dysregulation is a key factor in the development of schizophrenia. Excess dopamine activity in certain brain regions is associated with positive symptoms of schizophrenia, such as hallucinations and delusions. Dopaminergic medications that reduce dopamine levels are often used to manage these symptoms, further supporting the role of dopamine in schizophrenia. Serotonin (Choice A) is more commonly associated with mood regulation and is implicated in depression and anxiety disorders. Norepinephrine (Choice B) is involved in the body's 'fight or flight' response and is linked to conditions like anxiety and PTSD. Acetylcholine (Choice D) plays a role in muscle movement and memory but is not primarily implicated in schizophrenia.

4. While auditing care plans for clients with eating disorders, the nurse realizes that a nursing diagnosis appropriate for a client with anorexia nervosa as well as for a client with bulimia nervosa is

• A. Risk for imbalanced body temperature
• B. Ineffective denial
• C. Chronic low self-esteem
• D. Adult failure to thrive

Correct answer: C

Rationale: Chronic low self-esteem is a nursing diagnosis that can be applicable to clients with both anorexia nervosa and bulimia nervosa. These eating disorders are often associated with distorted body image, feelings of inadequacy, and low self-esteem. Clients with these conditions may engage in harmful behaviors related to their self-image, making chronic low self-esteem a relevant nursing diagnosis for them.

5. A client with schizophrenia is experiencing auditory hallucinations. Which nursing intervention is most appropriate to address this symptom?

• A. Encourage the client to discuss the voices.
• B. Instruct the client to listen to music to drown out the voices.
• C. Tell the client that the voices are not real.
• D. Distract the client from the voices.

Correct answer: A

Rationale: Encouraging the client to discuss the voices is the most appropriate nursing intervention when a client with schizophrenia is experiencing auditory hallucinations. By discussing the voices, the client can feel heard, understood, and supported. It allows the client to express their experiences, which can help in processing and coping with the hallucinations. This intervention promotes therapeutic communication and builds a trusting nurse-client relationship, which is essential in providing effective care for individuals with schizophrenia. Choice B is incorrect because instructing the client to listen to music to drown out the voices does not address the underlying issue and may not be effective in managing auditory hallucinations. Choice C is incorrect because telling the client that the voices are not real can invalidate the client's experiences and feelings, leading to further distress. Choice D is incorrect as solely distracting the client from the voices does not help in addressing the hallucinations or supporting the client in dealing with their symptoms.

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