Nursing Elites

1. A client with schizophrenia explains that she has 20 children and then very seriously points to the nurse and explains that she is one of them. What is the most therapeutic response for the nurse to provide?

• A. Let’s go ask another nurse if this is true.
• B. My name tag shows that I am a nurse here.
• C. I cannot possibly be one of your children.
• D. I know that you don’t have 20 children.

Correct answer: B

Rationale: Option B, 'My name tag shows that I am a nurse here,' is the most appropriate response as it provides clear and factual information to help the client differentiate between reality and delusion. By pointing out a concrete piece of evidence, the nurse can gently guide the client back to reality without directly challenging or contradicting their belief. Option A, 'Let’s go ask another nurse if this is true,' delays addressing the issue and doesn't provide immediate clarification. Option C, 'I cannot possibly be one of your children,' directly contradicts the client's statement and may increase distress. Option D, 'I know that you don’t have 20 children,' does not address the client's belief and can be perceived as dismissive.

2. The nurse is completing the admission assessment of an underweight adolescent admitted to the psychiatric unit with a diagnosis of depression. Which finding requires notification to the healthcare provider?

• A. Body mass index of 21
• B. Potassium level of 2.9 mEq/dL
• C. WBC count of 10,000/mm3
• D. Blood pressure of 110/70 mmHg

Correct answer: B

Rationale: The correct answer is B. A potassium level of 2.9 mEq/dL is critically low and requires immediate notification to the healthcare provider as it indicates a potential electrolyte imbalance, which can lead to serious cardiac arrhythmias and other complications. Choices A, C, and D are within normal ranges or not indicative of immediate life-threatening issues. A body mass index of 21 may be considered normal for some individuals, a WBC count of 10,000/mm3 is slightly elevated but not an urgent concern, and a blood pressure of 110/70 mmHg is within normal limits for an adolescent.

3. A woman brings her 48-year-old husband to the outpatient psychiatric unit and describes his behavior to the admitting nurse. She states that he has been sleepwalking, cannot remember who he is, and exhibits multiple personalities. The nurse knows that these behaviors are often associated with:

• A. Post-traumatic stress disorder.
• B. Panic disorder.
• C. Dissociative identity disorder.
• D. Obsessive-compulsive disorder.

Correct answer: C

Rationale: The correct answer is C: Dissociative identity disorder. Dissociative identity disorder (DID) is characterized by the presence of two or more distinct personality states or identities, along with memory gaps beyond ordinary forgetfulness. The description of the husband sleepwalking, not recognizing his identity, and exhibiting multiple personalities aligns with the symptoms of DID. Post-traumatic stress disorder (PTSD) (Choice A) involves re-experiencing traumatic events, panic disorder (Choice B) is characterized by recurrent panic attacks, and obsessive-compulsive disorder (OCD) (Choice D) involves obsessions and compulsions. These conditions do not typically present with the specific symptoms described in the scenario.

4. A female client, who is wearing dirty clothes and has a foul body odor, comes to the clinic reporting feeling scared because she is being stalked. What should the nurse do first?

• A. Offer the client a safe place to relax before interviewing her.
• B. Ask the client to describe why she is being stalked.
• C. Recommend that the client talk with a social worker.
• D. Assure the client that the healthcare provider will see her today.

Correct answer: A

Rationale: When a client presents with signs of distress and potential safety concerns, the priority is to provide a safe environment. Offering a safe place to relax can help the client feel secure and ready for further assessment and support. This action allows the nurse to establish rapport, ensure the client's immediate safety, and create a trusting relationship before delving into the details of the situation. Asking the client to describe why she is being stalked (Choice B) may exacerbate her distress and should come after ensuring her safety. Recommending that the client talk with a social worker (Choice C) is important but should follow immediate safety measures. Assuring the client that the healthcare provider will see her today (Choice D) is less critical than addressing her safety concerns and emotional state.

5. 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.

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