Nursing Elites

1. A client with major depressive disorder is prescribed a selective serotonin reuptake inhibitor (SSRI). Which side effect should the nurse educate the client about?

• A. Hypertension.
• B. Sexual dysfunction.
• C. Increased appetite.
• D. Weight gain.

Correct answer: B

Rationale: The correct answer is B: Sexual dysfunction. Sexual dysfunction is a common side effect of SSRIs. While hypertension (A) can occur with other medications, it is not typically associated with SSRIs. Increased appetite (C) and weight gain (D) are potential side effects of some antidepressants, but sexual dysfunction is more specific to SSRIs. Therefore, the nurse should educate the client about the risk of sexual dysfunction when taking an SSRI.

2. A female victim of sexual assault is being seen in the crisis center. The client states that she still feels 'as though the rape just happened yesterday,' even though it has been a few months since the incident. The appropriate nursing response is which of the following?

• A. You need to try to be realistic. The rape did not just occur.
• B. It will take some time to get over these feelings about your rape.
• C. Tell me more about the incident that causes you to feel like the rape just occurred.
• D. What do you think you can do to alleviate some of your fears about being raped again?

Correct answer: C

Rationale: The correct response is to encourage the client to talk about the event that makes them feel as though the rape just occurred. This approach can help the client process their feelings and experiences, which is crucial in dealing with trauma. Choice A is dismissive and negates the client's feelings, which can be harmful. Choice B, although acknowledging the time needed to heal, does not actively address the client's current feelings. Choice D shifts the focus to future fears rather than addressing the client's current emotional state.

3. A client with Alzheimer's disease is becoming increasingly agitated and combative in the late afternoon. What is the most appropriate intervention?

• A. Offer a sedative medication to calm the client.
• B. Encourage the client to rest in a quiet, low-stimulation environment.
• C. Use reality orientation to reduce confusion.
• D. Engage the client in physical activity to reduce agitation.

Correct answer: B

Rationale: Encouraging the client to rest in a quiet, low-stimulation environment is the most appropriate intervention for a client with Alzheimer's disease who is becoming agitated and combative in the late afternoon. This approach helps reduce agitation and prevent overstimulation, providing a calming and soothing environment for the client. Offering a sedative medication (Choice A) should be avoided as it may have side effects and should only be considered as a last resort. Reality orientation (Choice C) may increase confusion and distress in clients with advanced Alzheimer's disease. Engaging the client in physical activity (Choice D) could potentially escalate the agitation rather than reduce it in this scenario.

4. An elderly female client with advanced dementia is admitted to the hospital with a fractured hip. The client repeatedly tells the staff, 'Take me home. I want my Mommy.' Which response is best for the nurse to provide?

• A. Orient the client to the time, place, and person.
• B. Tell the client that the nurse is there and will help her.
• C. Remind the client that her mother is no longer living.
• D. Explain the seriousness of her injury and need for hospitalization.

Correct answer: B

Rationale: Those with dementia often refer to home or parents when seeking security and comfort. The nurse should use the techniques of 'offering self' and 'talking to the feelings' to provide reassurance (B). Clients with advanced dementia have permanent physiological changes in the brain (plaques and tangles) that prevent them from comprehending and retaining new information, so choices A, C, and D are likely to be of little use to this client and do not address the emotional needs expressed by the client. Option B acknowledges the client's feelings, offers support, and provides reassurance, which can help comfort the client during this distressing time.

5. During a manic episode, what is the most appropriate nursing intervention for a client with bipolar disorder?

• A. Allow the client to engage in any activities they choose.
• B. Provide a quiet and structured environment.
• C. Encourage the client to participate in group activities.
• D. Allow the client to take short naps during the day.

Correct answer: B

Rationale: During a manic episode, individuals with bipolar disorder often experience excessive energy and impulsivity. Providing a quiet and structured environment is crucial to help manage these symptoms. This intervention promotes stability, reduces overstimulation, and supports the client in regaining control over their behaviors. Choices A and C may exacerbate impulsivity and overstimulation, while choice D does not address the need for environmental structure and may not be effective in managing manic symptoms.

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