Nursing Elites

1. A healthcare professional is caring for a group of clients. Which of the following clients should the healthcare professional consider for referral to an assertive community treatment (ACT) group?

• A. A client in an acute care mental health facility who has fallen several times while running down the hallway
• B. A client who lives at home and keeps forgetting to come in for a scheduled monthly antipsychotic injection for schizophrenia
• C. A client in a day treatment program who reports increasing anxiety during group therapy
• D. A client in a weekly grief support group who reports still missing a deceased partner who has been dead for 3 months

Correct answer: B

Rationale: The client who lives at home and repeatedly forgets to come in for a scheduled monthly antipsychotic injection for schizophrenia should be considered for referral to an assertive community treatment (ACT) group. ACT teams provide intensive community-based treatment and support for individuals with severe mental illness who may have difficulty adhering to treatment on their own. Choices A, C, and D do not describe individuals with severe mental illness who have difficulty adhering to treatment or need intensive community-based support, which are the typical candidates for referral to an ACT group.

2. A patient is receiving education about taking clozapine. Which statement indicates the patient understands the side effects?

• A. I should report any signs of infection to my healthcare provider immediately.
• B. I can stop taking this medication once I feel better.
• C. I should take this medication on an empty stomach.
• D. I should avoid drinking alcohol while taking this medication.

Correct answer: A

Rationale: The correct answer is A because patients taking clozapine should report signs of infection immediately due to the risk of agranulocytosis. Agranulocytosis is a potentially life-threatening side effect of clozapine characterized by a significant decrease in white blood cell count, which can leave the patient vulnerable to infections. Reporting signs of infection promptly is crucial to prevent serious complications.

3. When developing a care plan for a patient with generalized anxiety disorder (GAD), which short-term goal is most appropriate?

• A. The patient will experience no episodes of anxiety within the next week.
• B. The patient will learn and practice relaxation techniques.
• C. The patient will avoid all anxiety-provoking situations.
• D. The patient will be medication-free within a month.

Correct answer: B

Rationale: Option B, 'The patient will learn and practice relaxation techniques,' is the most appropriate short-term goal for managing generalized anxiety disorder. Teaching relaxation techniques can help the patient develop coping mechanisms and reduce anxiety levels in the immediate future, making it a realistic and beneficial goal. Options A and C are not feasible in the short term as complete elimination of anxiety episodes or avoidance of all anxiety-provoking situations may not be achievable or practical within a week. Option D is not a suitable short-term goal as it overlooks the potential need for medication in managing generalized anxiety disorder.

4. In dissociative identity disorder, a patient exhibits different personalities, each with distinct behaviors and memories. The nurse recognizes that this fragmentation of identity serves as a coping mechanism for:

• A. Current stressors
• B. Developmental issues
• C. Traumatic experiences
• D. Family dynamics

Correct answer: C

Rationale: In dissociative identity disorder, the fragmentation of identity serves as a coping mechanism for traumatic experiences. Individuals may develop different identities to help them manage and cope with overwhelming and traumatic events from their past. These distinct personalities often emerge as a way to protect the individual from the emotional pain associated with their traumatic experiences. Choices A, B, and D are incorrect because dissociative identity disorder is primarily associated with coping mechanisms related to past traumatic experiences, rather than current stressors, developmental issues, or family dynamics.

5. A healthcare professional is assessing a patient with bipolar disorder. Which finding suggests the patient is experiencing a manic episode?

• A. Decreased need for sleep
• B. Feelings of worthlessness
• C. Increased need for sleep
• D. Avoidance of social interactions

Correct answer: A

Rationale: During a manic episode in patients with bipolar disorder, they often experience a decreased need for sleep. This symptom is characterized by feeling rested after only a few hours of sleep, or even feeling like they can go without sleep for extended periods without feeling tired. The increased energy levels and racing thoughts during a manic episode contribute to the decreased need for sleep.

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