Nursing Elites

1. 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.

2. A patient with a diagnosis of panic disorder is prescribed an SSRI. Which side effect should the nurse monitor for when the patient starts this medication?

• A. Increased heart rate
• B. Increased appetite
• C. Gastrointestinal disturbances
• D. Dry mouth

Correct answer: C

Rationale: When a patient with panic disorder is prescribed an SSRI, the nurse should monitor for gastrointestinal disturbances as a common side effect. SSRIs can cause gastrointestinal symptoms such as nausea, diarrhea, or abdominal discomfort, especially at the beginning of treatment. Increased heart rate (Choice A) is not a common side effect of SSRIs; it is more commonly associated with medications like stimulants. Increased appetite (Choice B) is not a typical side effect of SSRIs, as they are more likely to cause weight loss or appetite suppression. Dry mouth (Choice D) is a side effect seen more commonly with medications that have anticholinergic properties, not typically with SSRIs.

3. Child protective services have removed 10-year-old Christopher from his parents’ home due to neglect. Christopher reveals to the nurse that he considers the woman next door his “nice” mom, that he loves school, and gets above-average grades. The strongest explanation for this response is:

• A. Temperament
• B. Genetic factors
• C. Resilience
• D. Paradoxical effects of neglect

Correct answer: C

Rationale: Resilience is the ability to adapt well despite adversity, which is demonstrated by Christopher's positive relationships and school performance. Despite the challenging situation of being removed from his parents' home, Christopher's ability to form a positive bond with the neighbor, enjoy school, and excel academically showcases his resilience in coping with the circumstances.

4. A patient with major depressive disorder is started on fluoxetine. What is a common side effect the nurse should monitor for?

• A. Weight gain
• B. Increased appetite
• C. Nausea
• D. Dry mouth

Correct answer: C

Rationale: Nausea is a common side effect of fluoxetine and should be monitored.

5. A nurse hears a newly licensed nurse discussing a client’s hallucinations in the hallway with another nurse. Which of the following actions should the nurse take first?

• A. Notify the nurse manager
• B. Tell the nurse to stop discussing the behavior
• C. Provide an in-service program about confidentiality
• D. Complete an incident report

Correct answer: B

Rationale: The correct action the nurse should take first in this situation is to tell the newly licensed nurse to stop discussing the client's hallucinations with another nurse. Maintaining client confidentiality is a critical aspect of nursing practice. By addressing the behavior immediately, the nurse helps prevent the inappropriate sharing of sensitive information about a client. Choice A is not the first action to take because addressing the behavior directly is more immediate and can prevent further breaches of confidentiality. Choice C is not the priority at this moment as immediate action is required to address the current situation. Choice D, completing an incident report, should come after addressing the immediate issue and ensuring that the inappropriate behavior ceases.

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