Nursing Elites

1. A healthcare professional is assessing a client who is experiencing severe anxiety. Which of the following symptoms should the healthcare professional expect to observe?

• A. Restlessness
• B. Rapid heart rate
• C. Sweating
• D. Dry mouth

Correct answer: B

Rationale: Rapid heart rate is a characteristic symptom of severe anxiety due to the body's fight-or-flight response being activated. This physiological response leads to an increased heart rate to prepare the body to deal with perceived threats. Healthcare professionals should be vigilant in monitoring and managing this symptom in clients experiencing severe anxiety.

2. How should the nurse characterize the client's appraisal of the job loss stressor?

• A. Irrelevant
• B. Harm/loss
• C. Threatening
• D. Challenging

Correct answer: D

Rationale: The client's statement reflects a positive outlook on the job loss, viewing it as a challenge and an opportunity for personal growth. This perspective suggests that the client is resilient and adaptive, focusing on new possibilities rather than dwelling on the negative aspects of the situation. Choice D, 'Challenging,' is the correct characterization as it aligns with the client's positive appraisal. Choices A, 'Irrelevant,' B, 'Harm/loss,' and C, 'Threatening,' are incorrect as they do not capture the client's adaptive response to the stressor.

3. When assessing a client diagnosed with post-traumatic stress disorder (PTSD), which finding should the nurse expect?

• A. Hypervigilance
• B. Insomnia
• C. Flashbacks
• D. Suicidal ideation

Correct answer: A

Rationale: Clients with PTSD commonly exhibit symptoms such as hypervigilance, insomnia, flashbacks, difficulty concentrating, and increased irritability. Hypervigilance refers to an enhanced state of awareness and alertness, often seen in individuals with PTSD as they are constantly on guard for potential threats. Insomnia is a common sleep disturbance associated with PTSD, where individuals may have trouble falling or staying asleep. Flashbacks involve re-experiencing the traumatic event as if it is occurring in the present moment. Suicidal ideation, while a serious concern in mental health, is not a hallmark symptom specifically associated with PTSD. Therefore, the correct finding that the nurse should expect when assessing a client diagnosed with PTSD is hypervigilance.

4. A client with schizophrenia is experiencing auditory hallucinations. Which nursing intervention is most appropriate to address this symptom?

• A. Encourage the client to discuss the voices.
• B. Instruct the client to listen to music to drown out the voices.
• C. Tell the client that the voices are not real.
• D. Distract the client from the voices.

Correct answer: A

Rationale: Encouraging the client to discuss the voices is the most appropriate nursing intervention when a client with schizophrenia is experiencing auditory hallucinations. By discussing the voices, the client can feel heard, understood, and supported. It allows the client to express their experiences, which can help in processing and coping with the hallucinations. This intervention promotes therapeutic communication and builds a trusting nurse-client relationship, which is essential in providing effective care for individuals with schizophrenia. Choice B is incorrect because instructing the client to listen to music to drown out the voices does not address the underlying issue and may not be effective in managing auditory hallucinations. Choice C is incorrect because telling the client that the voices are not real can invalidate the client's experiences and feelings, leading to further distress. Choice D is incorrect as solely distracting the client from the voices does not help in addressing the hallucinations or supporting the client in dealing with their symptoms.

5. During a mental status examination, which of the following components should not be included in the assessment?

• A. Appearance and behavior
• B. Giving advice
• C. Mood and affect
• D. Cognitive function

Correct answer: B

Rationale: During a mental status examination, components such as appearance and behavior, mood and affect, and cognitive function are assessed. Giving advice is not a component of a mental status examination as it focuses on evaluating the client's mental state rather than providing guidance or recommendations.

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