Nursing Elites

1. A client with post-traumatic stress disorder (PTSD) is experiencing flashbacks. Which of the following interventions should the nurse implement?

• A. Encourage the client to ignore the flashbacks.
• B. Stay with the client and offer reassurance.
• C. Instruct the client to avoid discussing the traumatic event.
• D. Encourage the client to engage in group therapy.

Correct answer: B

Rationale: During a flashback, it is essential for the nurse to stay with the client and offer reassurance. This approach can help the client feel safe and supported during a distressing experience. Encouraging the client to ignore the flashbacks may lead to increased anxiety and distress. Instructing the client to avoid discussing the traumatic event can hinder the therapeutic process of addressing and processing the trauma. While group therapy can be beneficial, it may not be the immediate intervention needed during a flashback.

2. A client with major depressive disorder is receiving cognitive-behavioral therapy (CBT). Which outcome indicates that the therapy is effective?

• A. The client identifies and challenges negative thoughts.
• B. The client reports an increase in suicidal thoughts.
• C. The client experiences an increase in anxiety.
• D. The client shows no change in behavior.

Correct answer: A

Rationale: In cognitive-behavioral therapy, identifying and challenging negative thoughts is a fundamental aspect of the treatment process. This cognitive restructuring helps individuals with major depressive disorder to develop healthier thinking patterns and cope more effectively with their emotions, which ultimately leads to improvement in their mental health. Therefore, when a client is able to identify and challenge negative thoughts, it indicates that they are actively engaging in the therapeutic process and making progress towards better mental well-being.

3. A client diagnosed with borderline personality disorder has been admitted to the psychiatric unit after a suicide attempt. Which of the following actions should the nurse take first?

• A. Encourage the client to express feelings about the suicide attempt.
• B. Place the client on one-to-one observation.
• C. Discuss the client's feelings about the suicide attempt.
• D. Encourage the client to participate in group therapy.

Correct answer: B

Rationale: The initial priority for the nurse is to ensure the safety of the client. Placing the client on one-to-one observation allows for constant monitoring and intervention if there are any signs of self-harm or a worsening condition. This immediate intervention is crucial to prevent further harm. Options A, C, and D involve therapeutic communication and interventions, which are important but should come after ensuring the client's safety.

4. A client diagnosed with schizophrenia is receiving discharge teaching. Which of the following instructions should the healthcare provider include? Select one that does not apply.

• A. Continue taking medications as prescribed
• B. Avoid all social interactions
• C. Report any side effects of medications to the healthcare provider
• D. Develop a daily routine

Correct answer: B

Rationale: Discharge instructions for a client diagnosed with schizophrenia should focus on promoting medication adherence, monitoring and reporting any medication side effects, and establishing a structured daily routine to support stability and well-being. Encouraging the client to avoid all social interactions is not appropriate as social support can be beneficial for individuals with schizophrenia. Social interactions can help reduce feelings of isolation, improve overall well-being, and provide emotional support. Therefore, advising the client to avoid all social interactions would not be in the best interest of their recovery and management of the condition.

5. During an intake assessment, a nurse asks both physiological and psychosocial questions. The client angrily responds, 'I'm here for my heart, not my head problems.' What is the nurse's best response?

• A. It's just a routine part of our assessment. All clients are asked these same questions.
• B. Why are you concerned about these types of questions?
• C. Psychological factors, like excessive stress, have been found to affect medical conditions.
• D. We can skip these questions, if you like. It isn't imperative that we complete this section.

Correct answer: C

Rationale: The nurse should educate the client about the impact of psychological factors, such as excessive stress, on medical conditions. Understanding this connection is crucial in providing holistic care. It is essential to address both physiological and psychosocial aspects during the assessment to obtain a comprehensive understanding of the client's health status and needs. Choice A is incorrect as it doesn't address the importance of psychosocial aspects on medical conditions. Choice B is not the best response as it does not provide valuable information about the connection between psychological factors and medical conditions. Choice D is incorrect because skipping these questions could lead to missing crucial information that may impact the client's overall well-being and treatment plan.

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