Nursing Elites

1. A client with borderline personality disorder is admitted to the psychiatric unit. Which intervention should the nurse implement to promote the client's safety?

• A. Implement a no-harm contract with the client.
• B. Monitor the client closely for signs of self-harm.
• C. Encourage the client to participate in recreational activities.
• D. Encourage the client to maintain a structured daily routine.

Correct answer: A

Rationale: When a client with borderline personality disorder is admitted to a psychiatric unit, implementing a no-harm contract is a crucial intervention to promote the client's safety. A no-harm contract is a formal agreement between the client and the healthcare provider stating that the client commits to not harm themselves or others. This intervention helps in establishing boundaries and promoting safety by enhancing communication and accountability between the client and the healthcare team. Monitoring the client closely for signs of self-harm (Choice B) is important but does not directly address promoting safety through a formal agreement. Encouraging participation in recreational activities (Choice C) and maintaining a structured daily routine (Choice D) are beneficial interventions but may not directly address the immediate safety concerns of a client with borderline personality disorder.

2. During a mental status examination, which of the following components should be included in the assessment? Select one that doesn't apply.

• A. Appearance and behavior
• B. Thought processes
• C. Mood and affect
• D. The greater the cultural distance from the mainstream of society, the greater the likelihood that the illness will be treated with sensitivity and compassion.

Correct answer: D

Rationale: During a mental status examination, key components to be assessed include the client's appearance and behavior, thought processes, mood and affect, and cognitive function. These components help in evaluating the client's mental health status. The statement about cultural distance and illness treatment is not a part of a mental status examination and is not relevant to the assessment of mental health. Choices A, B, and C are essential components of a mental status examination and contribute to a comprehensive evaluation of an individual's mental well-being.

3. A nurse is assessing a patient with schizophrenia who is experiencing delusions. Which intervention is most appropriate?

• A. Agree with the patient's delusions to avoid confrontation.
• B. Encourage the patient to explore the basis of the delusions.
• C. Engage the patient in reality-based activities.
• D. Ask the patient to explain the delusions in detail.

Correct answer: C

Rationale: The most appropriate intervention when assessing a patient with schizophrenia experiencing delusions is to engage the patient in reality-based activities. This intervention helps distract the patient from the delusions and reorients them to the present, promoting grounding in reality. Choice A is incorrect because agreeing with delusions can reinforce them and hinder treatment. Choice B may exacerbate the delusions by delving deeper into their basis. Choice D may not be beneficial as it focuses solely on the delusions without addressing the need to ground the patient in reality.

4. What information should the nurse provide in patient education for a patient prescribed sertraline for major depressive disorder?

• A. Take the medication with food.
• B. It may take several weeks to feel the full effect.
• C. Avoid consuming grapefruit while taking this medication.
• D. Regular blood tests are necessary to monitor levels.

Correct answer: B

Rationale: Patients prescribed sertraline for major depressive disorder should be educated that it may take several weeks before experiencing the full therapeutic effects of the medication. This delay in onset of action is common with antidepressants like sertraline, and patients need to be aware of this to manage their expectations and continue with the treatment regimen. It's important for the patient to understand that consistent adherence to the prescribed dosage is crucial, even if the full effects are not immediately apparent. Choices A, C, and D are incorrect because taking the medication with food, avoiding grapefruit, and regular blood tests are not specific education points related to the expected timeframe for therapeutic effects of sertraline.

5. A client diagnosed with generalized anxiety disorder (GAD) states, 'I just can't stop worrying about everything.' Which nursing diagnosis is most appropriate for this client?

• A. Ineffective coping
• B. Disturbed thought processes
• C. Chronic low self-esteem
• D. Social isolation

Correct answer: A

Rationale: The most appropriate nursing diagnosis for a client with generalized anxiety disorder (GAD) who expresses an inability to stop worrying about everything is 'Ineffective coping.' This diagnosis indicates the client's struggle to manage anxiety and worry effectively, which aligns with the client's statement. 'Disturbed thought processes' (Choice B) would involve disorganized or irrational thinking patterns, which are not directly related to the client's statement about excessive worry. 'Chronic low self-esteem' (Choice C) refers to a long-standing negative self-evaluation and is not the most fitting diagnosis for the client's current concern. 'Social isolation' (Choice D) pertains to a lack of social interactions and support, which is not the primary issue highlighted by the client's statement.

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