Nursing Elites

1. A client is being assessed by a nurse for increased anxiety, restlessness, and insomnia. Which of the following interventions is the first priority for the nurse?

• A. Administer anti-anxiety medications as prescribed by the healthcare provider
• B. Engage in a conversation with the client regarding methods to enhance rest and sleep
• C. Escort the client to a private room and stay with them
• D. Review the client's medical history to determine previous treatment for these issues

Correct answer: C

Rationale: The first priority when dealing with a client experiencing potential mental health issues is to ensure their safety. Taking the client to a private room helps to reduce external stimuli and staying with them ensures constant monitoring and support. This intervention can prevent any escalation of anxiety or restlessness and promote a sense of security for the client. Engaging in a conversation about improving rest and sleep is important but ensuring immediate safety takes precedence. Administering medications should only be done after the client's safety is assured. Reviewing the client's medical history, while important, is not the immediate priority when the client is exhibiting acute symptoms of anxiety and restlessness.

2. The nurse develops a goal that makes a client feel as if they are engaging in a competition. Which type of motivation is the nurse using in this situation?

• A. Power motivation
• B. Affiliative motivation
• C. Avoidance motivation
• D. Achievement motivation

Correct answer: A

Rationale: The nurse is using power motivation in this situation. Power-motivated individuals tend to have assertive and aggressive behavior. By designing goals that make clients feel like they are in a competition, the nurse appeals to their need for power and accomplishment, even when they are competing against themselves. Affiliative motivation is characterized by nonassertive behavior and dependence on others, which is not applicable here. Avoidance motivation focuses on anxiety, fear of failure, and phobias, which are not relevant to the scenario. Achievement motivation does not involve aggressive behavior or the need for competition, making it an incorrect choice for this scenario.

3. Which risk factor for suicide is considered the most lethal?

• A. History of alcohol and drug abuse
• B. Previous high-lethality suicide attempts
• C. Recent withdrawal from friends
• D. Disturbance of family dynamics

Correct answer: B

Rationale: The correct answer is 'Previous high-lethality suicide attempts.' This is the most lethal risk factor as it indicates that the individual has previously attempted suicide in a manner that could lead to death. This history increases the likelihood of future attempts. While substance abuse, like alcohol and drug use, is a significant risk factor for suicide, it is not considered the most lethal. Withdrawal from friends or social isolation can contribute to suicide risk but is not as directly deadly as high-lethality attempts. Disturbance of family dynamics can also be a stressor but does not represent the immediate lethality associated with a history of high-lethality suicide attempts.

4. What does the E in the acronym DELIRIUM represent in causes contributing to delirium?

• A. EEG
• B. EKG
• C. Electrolytes
• D. Echocardiogram

Correct answer: C

Rationale: The E in the acronym DELIRIUM stands for Electrolytes. Electrolyte imbalances can lead to delirium. The other letters in the acronym represent: D = Dementia; L = Lung, liver, heart, kidney, brain; I = Infection; R = Rx Drugs; I = Injury, Pain, Stress; U = Unfamiliar environment; M = Metabolic. It is crucial to differentiate delirium from dementia, as delirium is often reversible with treatment of underlying causes. Dementia should only be considered after ruling out delirium, as addressing the contributing factors may alleviate the delirium state.

5. Before discharging an anxious client, which information about anxiety would the nurse teach the family?

• A. Anxiety is a totally unique feeling and experience.
• B. Apprehension is generalized to the total environment.
• C. Fears result from conscious actions, thoughts, and wishes.
• D. Anxiety is a pattern of emotional and behavioral responses to stress.

Correct answer: D

Rationale: Anxiety is a human response consisting of both physical and emotional changes that everyone experiences when faced with stressful situations. It is a pattern of emotional and behavioral responses to stress. Anxiety is a common experience for many individuals. Apprehension is usually related to a specific aspect of the environment rather than the total environment. Fears are not intentionally or consciously generated.

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