Nursing Elites

1. A healthcare professional is assessing a client diagnosed with anorexia nervosa. Which of the following findings shouldn't the professional expect?

• A. Amenorrhea
• B. Lanugo
• C. Hypotension
• D. Hyperkalemia

Correct answer: D

Rationale: When assessing a client diagnosed with anorexia nervosa, healthcare professionals should expect findings such as amenorrhea, lanugo, hypotension, and bradycardia. Hyperkalemia is not typically associated with anorexia nervosa; instead, hypokalemia, which is low potassium levels, is more commonly seen in these individuals due to malnutrition and other factors.

2. Which of the following interventions should a nurse include in the care plan for a client with major depressive disorder? Select one that is not appropriate.

• A. Encourage participation in activities
• B. Promote adequate nutrition and hydration
• C. Discourage verbalization of feelings
• D. Monitor for suicidal ideation

Correct answer: C

Rationale: Interventions for a client with major depressive disorder should focus on encouraging participation in activities, promoting adequate nutrition and hydration, monitoring for suicidal ideation, and providing a structured daily schedule. Discouraging verbalization of feelings goes against the therapeutic approach as expressing and discussing feelings is crucial in the treatment of major depressive disorder. Clients with major depressive disorder often benefit from talking about their emotions and experiences, as it can help in processing their feelings and promoting recovery. Therefore, discouraging verbalization of feelings would hinder the client's progress and is not an appropriate intervention.

3. During an assessment, a nurse observes a client showing signs of moderate anxiety. Which symptom is not typically associated with moderate anxiety?

• A. Fidgeting
• B. Laughing inappropriately
• C. Palpitations
• D. Nail biting

Correct answer: C

Rationale: When assessing a client with moderate anxiety, the nurse should anticipate signs such as fidgeting, laughing inappropriately, and nail biting. These behaviors are common manifestations of increased stress levels. Palpitations, on the other hand, are more commonly associated with severe anxiety or panic attacks. Other symptoms of severe anxiety may include restlessness, difficulty concentrating, muscle tension, and sleep disturbances.

4. A woman was abducted and raped at gunpoint by an unknown assailant. When found, she was confused and disoriented. The nurse makes the following observations about the client. She is talking rapidly in disjointed phrases, is unable to concentrate, and is indecisive when asked to make simple decisions. The client's level of anxiety can be assessed as

• A. moderate
• B. severe
• C. mild
• D. nonexistent

Correct answer: B

Rationale: The client's presentation, including rapid and disjointed speech, inability to concentrate, and indecisiveness, are indicative of severe anxiety. These symptoms suggest a high level of distress and impairment in cognitive functioning, which aligns with severe anxiety rather than mild or moderate levels. The traumatic experience of being abducted and raped at gunpoint would likely contribute to such a severe level of anxiety.

5. A healthcare professional is assessing a client's use of defense mechanisms. Which statement would indicate to the healthcare professional that the client is using the defense mechanism of projection?

• A. The client accuses others of being angry when it is the client who is angry.
• B. The client refuses to acknowledge a problem despite evidence to the contrary.
• C. The client attributes his own feelings of hostility to others.
• D. The client avoids dealing with painful feelings by focusing on something else.

Correct answer: C

Rationale: Projection is a defense mechanism where individuals attribute their own unacceptable feelings, thoughts, or impulses onto others. In this case, the client is projecting his own feelings of hostility onto others by assuming they possess these feelings instead.

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