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. A distraught, single, first-time mother cries and asks a nurse, 'How can I go to work if I can't afford childcare?' What is the nurse's initial action in assisting the client with the problem-solving process?

• A. Determine the risks and benefits for each alternative.
• B. Formulate goals for resolution of the problem.
• C. Evaluate the outcome of the implemented alternative.
• D. Assess the facts of the situation.

Correct answer: D

Rationale: In this scenario, the nurse's initial step should be to assess the facts of the situation. By gathering accurate information about the client's circumstances, the nurse can better understand the problem and make informed decisions moving forward. This foundational assessment is crucial before proceeding to formulate goals, evaluate outcomes, or consider risks and benefits. Options A, B, and C involve steps that should follow the initial assessment of the situation, making them less suitable as the initial action in this context.

3. A nurse is providing education to a client who has been prescribed lithium for bipolar disorder. Which statement by the client indicates an accurate understanding of the medication?

• A. I should avoid eating aged cheeses and processed meats.
• B. I need to maintain a consistent sodium intake.
• C. I should drink plenty of fluids to stay hydrated.
• D. I can take over-the-counter medications without consulting my doctor.

Correct answer: B

Rationale: Clients taking lithium should maintain a consistent sodium intake to avoid fluctuations in lithium levels.

4. A client diagnosed with borderline personality disorder has been admitted to the psychiatric unit after a suicide attempt. Which of the following actions should the nurse take first?

• A. Encourage the client to express feelings about the suicide attempt.
• B. Place the client on one-to-one observation.
• C. Discuss the client's feelings about the suicide attempt.
• D. Encourage the client to participate in group therapy.

Correct answer: B

Rationale: The initial priority for the nurse is to ensure the safety of the client. Placing the client on one-to-one observation allows for constant monitoring and intervention if there are any signs of self-harm or a worsening condition. This immediate intervention is crucial to prevent further harm. Options A, C, and D involve therapeutic communication and interventions, which are important but should come after ensuring the client's safety.

5. In the care plan of a male patient diagnosed with a dissociative disorder, the nursing diagnosis of ineffective coping is included. Which behavior demonstrated by the patient supports this nursing diagnosis?

• A. Has no memory of the physical abuse he endured.
• B. Using both alcohol and marijuana.
• C. Often reports being unaware of surroundings.
• D. Reports feelings of 'not really being here.'

Correct answer: B

Rationale: The correct answer is B because using substances like alcohol and marijuana can be a sign of ineffective coping mechanisms in patients with dissociative disorders. Substance abuse is often used as a maladaptive way to cope with stress, trauma, or other underlying issues. Choices A, C, and D may be related to dissociative symptoms but do not directly reflect ineffective coping behaviors as substance abuse does.

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