Nursing Elites

1. A nurse is assessing a client with generalized anxiety disorder (GAD) who reports difficulty concentrating and feeling restless. What is the most appropriate nursing intervention?

• A. Encourage the client to avoid caffeine.
• B. Suggest the client take up a new hobby.
• C. Teach the client deep breathing exercises.
• D. Refer the client to group therapy.

Correct answer: C

Rationale: Teaching deep breathing exercises is the most appropriate intervention for a client with generalized anxiety disorder (GAD) experiencing difficulty concentrating and restlessness. Deep breathing exercises are a proven technique to help manage anxiety symptoms, promote relaxation, and improve concentration. Encouraging the client to avoid caffeine (Choice A) may be beneficial, but it is not the most direct intervention for the reported symptoms. Suggesting the client take up a new hobby (Choice B) may be helpful for overall well-being but does not directly address the immediate symptoms. Referring the client to group therapy (Choice D) may be beneficial in the long term, but teaching deep breathing exercises is more immediate and can be easily implemented by the client in various settings.

2. An adult male client who was admitted to the mental health unit yesterday tells the nurse that microchips were planted in his head for military surveillance of his every move. Which response is best for the LPN/LVN to provide?

• A. You are in the hospital, and I am the nurse caring for you.
• B. It must be difficult for you to control your anxious feelings.
• C. Go to occupational therapy and start a project.
• D. You are not in a war area now; this is the United States.

Correct answer: A

Rationale: The best response for the LPN/LVN to provide is option A: 'You are in the hospital, and I am the nurse caring for you.' This response is effective as it grounds the client in the present reality while also acknowledging the client's feelings. It shows acceptance of the client's experience without directly challenging the delusional belief, which can help build rapport and trust. Option B focuses on anxiety rather than validating the client's experience or addressing the delusion. Option C suggests an unrelated activity that may not be helpful in this situation. Option D attempts to correct the client's belief, which is not likely to be effective in managing delusional thoughts.

3. A client with post-traumatic stress disorder (PTSD) reports having frequent nightmares. What is the nurse's best response?

• A. Nightmares are common with PTSD and should decrease over time.
• B. Try to avoid thinking about the trauma before going to bed.
• C. Let's discuss some relaxation techniques you can use before bedtime.
• D. I will ask the healthcare provider to prescribe a sleep aid.

Correct answer: C

Rationale: The best response for the nurse is to discuss relaxation techniques with the client that can help reduce anxiety and stress before bedtime. This approach may potentially decrease the frequency of nightmares by promoting a more calming and peaceful pre-sleep routine. Choice A is incorrect because while nightmares can be common with PTSD, it is not guaranteed that they will decrease over time. Choice B is incorrect as avoiding thinking about the trauma may not address the underlying issue causing the nightmares. Choice D is incorrect as prescribing a sleep aid should be considered as a last resort after trying non-pharmacological interventions.

4. The LPN/LVN is caring for a client with post-traumatic stress disorder (PTSD). Which intervention is most appropriate for the nurse to implement?

• A. Encourage the client to talk about the traumatic event.
• B. Assist the client in developing coping strategies.
• C. Refer the client to a PTSD support group.
• D. Administer prescribed medications to manage symptoms.

Correct answer: B

Rationale: Assisting the client in developing coping strategies is an appropriate intervention for managing PTSD. This approach helps the client build resilience and learn how to effectively cope with symptoms. Choice A, encouraging the client to talk about the traumatic event, may not be appropriate as it can potentially re-traumatize the client. Referring the client to a PTSD support group, as in choice C, can be beneficial but may not be the most immediate intervention. Administering medications, as in choice D, is important in some cases, but focusing on coping strategies should be prioritized as a holistic approach to managing PTSD.

5. A young adult female client is admitted to a psychiatric facility with a medical diagnosis of bulimia nervosa. Which nursing intervention has the highest priority?

• A. Schedule the client for group therapy with other clients with bulimia nervosa.
• B. Assign the client's care to a nurse with relevant experience in eating disorders.
• C. Monitor the client carefully for binging and purging activities.
• D. Assess and report the client's electrolyte status to the healthcare provider.

Correct answer: D

Rationale: The correct answer is D. Assessing and reporting the client's electrolyte status to the healthcare provider is the highest priority in a client with bulimia nervosa. Electrolyte imbalances, such as hypokalemia and metabolic alkalosis, are common due to purging behaviors associated with bulimia. Monitoring electrolyte levels is crucial to prevent life-threatening complications. Choices A, B, and C are incorrect because while therapy and monitoring for binging activities are important, addressing the electrolyte imbalances caused by purging behaviors takes precedence in the immediate care of a client with bulimia nervosa.

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