Nursing Elites

1. 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.

2. Which therapeutic approach is most effective for managing obsessive-compulsive disorder (OCD)?

• A. Cognitive-behavioral therapy
• B. Psychoanalysis
• C. Medication management
• D. Group therapy

Correct answer: A

Rationale: Cognitive-behavioral therapy (CBT), especially exposure and response prevention, is considered the most effective therapeutic approach for managing obsessive-compulsive disorder (OCD). CBT helps individuals identify and modify their distorted beliefs and behaviors related to OCD, while exposure and response prevention specifically target the core symptoms of OCD by gradually exposing the individual to feared stimuli and preventing compulsive responses. While medication management can be used as an adjunct to therapy, CBT has shown to have long-lasting benefits in reducing OCD symptoms and improving the overall quality of life. Psychoanalysis focuses more on exploring unconscious conflicts and childhood experiences, which may not be as effective for OCD. Group therapy can be beneficial as a supplemental treatment but is not typically as effective as individual CBT tailored to the specific needs of the individual with OCD.

3. A client has been diagnosed with depersonalization/derealization disorder. Which of the following behaviors should the nurse expect?

• A. Feelings of detachment from one's body
• B. Fear of gaining weight
• C. Paralysis of a limb
• D. Episodes of hypomania

Correct answer: A

Rationale: Depersonalization/derealization disorder is characterized by feelings of detachment from one's body or surroundings. Individuals with this disorder may feel like they are observing themselves from outside their body or that the world around them is unreal. Therefore, the nurse should expect behaviors such as feelings of detachment from one's body (A). Fear of gaining weight (B) is more indicative of an eating disorder, paralysis of a limb (C) could be related to neurological issues, and episodes of hypomania (D) are associated with mood disorders like bipolar disorder, but not specifically with depersonalization/derealization disorder.

4. A client diagnosed with generalized anxiety disorder (GAD) states, 'I just can't stop worrying about everything.' Which nursing diagnosis is most appropriate for this client?

• A. Ineffective coping
• B. Disturbed thought processes
• C. Chronic low self-esteem
• D. Social isolation

Correct answer: A

Rationale: The most appropriate nursing diagnosis for a client with generalized anxiety disorder (GAD) who expresses an inability to stop worrying about everything is 'Ineffective coping.' This diagnosis indicates the client's struggle to manage anxiety and worry effectively, which aligns with the client's statement. 'Disturbed thought processes' (Choice B) would involve disorganized or irrational thinking patterns, which are not directly related to the client's statement about excessive worry. 'Chronic low self-esteem' (Choice C) refers to a long-standing negative self-evaluation and is not the most fitting diagnosis for the client's current concern. 'Social isolation' (Choice D) pertains to a lack of social interactions and support, which is not the primary issue highlighted by the client's statement.

5. When assessing a client diagnosed with anorexia nervosa, which of the following findings should the nurse expect? Select one that does not apply.

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

Correct answer: D

Rationale: In a client diagnosed with anorexia nervosa, expected findings include amenorrhea, lanugo, hypotension, and bradycardia. Hyperkalemia is not typically associated with anorexia nervosa; instead, hypokalemia, which is low potassium levels, is more common. Hypokalemia can result from decreased intake of potassium-rich foods or excessive purging behaviors commonly seen in individuals with anorexia nervosa.

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