Nursing Elites

1. During an assessment, a client is demonstrating symptoms of moderate anxiety. Which of the following symptoms would be indicative of moderate anxiety?

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

Correct answer: C

Rationale: Palpitations are a common physical symptom seen in clients experiencing moderate anxiety. Fidgeting, laughing inappropriately, and nail biting can also indicate heightened stress levels. It's important for healthcare providers to recognize these signs and provide appropriate support. While anxiety can manifest in various ways, other indicators of moderate anxiety may include restlessness, difficulty concentrating, muscle tension, and sleep disturbance. It's crucial for healthcare providers to assess these symptoms to provide effective care and interventions. Laughing inappropriately and nail biting are more commonly associated with nervousness or social discomfort, while fidgeting may signal mild anxiety.

2. Which factors tend to increase the difficulty of diagnosing young children who demonstrate behaviors associated with mental illness? Select one that does not apply.

• A. Limited language skills
• B. Level of cognitive development
• C. Level of emotional development
• D. Parental denial that a problem exists

Correct answer: D

Rationale: Diagnosing mental illness in young children can be complex due to their limited language skills, cognitive development, and emotional development. However, parental denial does not directly affect the child's inherent challenges, making it the factor that does not apply to the difficulty of diagnosis.

3. A client with schizophrenia is experiencing auditory hallucinations. Which nursing intervention should the nurse implement to address this symptom?

• A. Encourage the client to express feelings about the hallucinations.
• B. Distract the client from the hallucinations.
• C. Provide reality-based feedback about the hallucinations.
• D. Encourage the client to ignore the hallucinations.

Correct answer: C

Rationale: The correct intervention for a client experiencing auditory hallucinations in schizophrenia is to provide reality-based feedback about the hallucinations. By providing reality-based feedback, the nurse helps the client differentiate between what is real and what is not, which can help decrease the distress and impact of the hallucinations on the client's perception of reality. Encouraging the client to express feelings (Choice A) may not directly address the hallucinations. Distracting the client (Choice B) may temporarily alleviate the symptoms but does not help the client differentiate reality from hallucinations. Encouraging the client to ignore the hallucinations (Choice D) may not be effective as the client may struggle to do so without appropriate guidance.

4. Kyle, a patient with schizophrenia, began taking the first-generation antipsychotic haloperidol (Haldol) last week. One day you find him sitting very stiffly and not moving. He is diaphoretic, and when you ask if he is okay, he seems unable to respond verbally. His vital signs are: BP 170/100, P 110, T 104.2°F. What is the priority nursing intervention? Select one that does not apply.

• A. Hold his medication and contact his prescriber.
• B. Wipe him with a washcloth wet with cold water or alcohol.
• C. Administer a medication such as benztropine IM to correct this dystonic reaction.
• D. Reassure him that although there is no treatment for his tardive dyskinesia, it will pass.

Correct answer: C

Rationale: The patient's symptoms, including stiffness, diaphoresis, inability to respond verbally, and vital sign abnormalities, are indicative of neuroleptic malignant syndrome (NMS), a serious and potentially life-threatening side effect of antipsychotic medications. Administering a medication such as benztropine intramuscularly is the priority to address the dystonic reaction associated with NMS. This intervention can help alleviate symptoms and prevent further complications. Holding the medication and contacting the prescriber may be necessary but addressing the acute symptoms takes precedence. Wiping the patient with a cold washcloth or alcohol would not address the underlying medical emergency. Reassuring the patient about tardive dyskinesia is irrelevant and not the immediate concern in this scenario.

5. When planning care for a client with schizophrenia, which of the following interventions should be included in the plan of care?

• A. Encourage reality testing
• B. Provide opportunities for socialization
• C. Monitor for command hallucinations
• D. Promote adherence to medication regimen

Correct answer: A

Rationale: When caring for a client with schizophrenia, encouraging reality testing is essential. This intervention assists the client in distinguishing between delusions and reality, aiding in their treatment. While providing opportunities for socialization can help reduce isolation, monitoring for command hallucinations is crucial for the client's safety. Promoting adherence to the medication regimen is vital for symptom management. Addressing delusional thoughts in a therapeutic manner is preferable to outright discouragement, fostering a supportive environment for the client.

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