Nursing Elites

1. When educating the family of a client diagnosed with dissociative identity disorder, which of the following instructions should the nurse include?

• A. Encourage the client to avoid stressful situations.
• B. Encourage the client to participate in daily activities.
• C. Encourage the client to express their feelings.
• D. Encourage the client to develop a daily routine.

Correct answer: D

Rationale: In cases of dissociative identity disorder, it is beneficial for the client to establish a daily routine. This structure can enhance symptom management and provide a sense of stability, which is particularly important for individuals with this condition. Encouraging the client to avoid stressful situations (Choice A) may not always be possible and does not address the need for structure. While encouraging the client to participate in daily activities (Choice B) is important, having a routine is more crucial for managing dissociative identity disorder. Expressing feelings (Choice C) is valuable but establishing a routine takes precedence in this situation.

2. Which intervention is most appropriate for a patient with a phobia of flying?

• A. Exposure therapy
• B. Cognitive restructuring
• C. Medication management
• D. Psychoeducation

Correct answer: A

Rationale: Exposure therapy is considered the most appropriate intervention for a patient with a phobia of flying. This therapeutic approach involves gradually exposing the individual to the feared stimulus, in this case, flying, in a controlled and supportive environment. By facing the fear in a structured manner, the patient can learn to manage their anxiety response and eventually reduce their phobia-related symptoms. While cognitive restructuring may help change negative thought patterns and medication management can alleviate symptoms, exposure therapy is specifically designed to address phobias through systematic desensitization, making it the most suitable intervention in this scenario. Psychoeducation aims to provide information and support but may not directly target the phobia itself.

3. When assessing a client experiencing severe anxiety, which symptom should the nurse expect to observe?

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

Correct answer: B

Rationale: When a client is experiencing severe anxiety, a rapid heart rate is a common physiological response. This increased heart rate is due to the body's fight-or-flight response, where adrenaline is released, causing the heart to beat faster. Monitoring the client's heart rate is crucial in assessing and managing their anxiety. Restlessness (choice A) can also be present in anxiety but is more of a behavioral manifestation rather than a physiological symptom. Sweating (choice C) can occur in anxiety, but it is not as specific or consistent as a rapid heart rate. Dry mouth (choice D) is associated with anxiety but is not as immediate or directly linked to the body's physiological response to stress as a rapid heart rate.

4. While auditing care plans for clients with eating disorders, the nurse realizes that a nursing diagnosis appropriate for a client with anorexia nervosa as well as for a client with bulimia nervosa is

• A. Risk for imbalanced body temperature
• B. Ineffective denial
• C. Chronic low self-esteem
• D. Adult failure to thrive

Correct answer: C

Rationale: Chronic low self-esteem is a nursing diagnosis that can be applicable to clients with both anorexia nervosa and bulimia nervosa. These eating disorders are often associated with distorted body image, feelings of inadequacy, and low self-esteem. Clients with these conditions may engage in harmful behaviors related to their self-image, making chronic low self-esteem a relevant nursing diagnosis for them.

5. A client is diagnosed with obsessive-compulsive disorder (OCD), and a nurse is planning care. Which of the following interventions should the nurse exclude from the care plan?

• A. Allowing the client to perform rituals initially
• B. Discouraging the client from washing their hands
• C. Monitoring for suicidal ideation
• D. Providing a structured schedule of activities

Correct answer: C

Rationale: The correct answer is monitoring for suicidal ideation. When caring for a client with OCD, interventions should include allowing the client to perform rituals initially, setting limits on the time allowed for rituals, encouraging the client to verbalize feelings, and providing a structured schedule of activities. Monitoring for suicidal ideation is crucial in assessing the client's safety and mental health status, but it is not a direct intervention specific to managing OCD symptoms.

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