Nursing Elites

1. What is the most appropriate nursing diagnosis for a patient with agoraphobia who reports not having left their house in months?

• A. Social isolation
• B. Ineffective coping
• C. Risk for injury
• D. Impaired social interaction

Correct answer: A

Rationale: The nursing diagnosis 'Social isolation' is most appropriate for a patient with agoraphobia who has not left their house in months. Agoraphobia often leads to the avoidance of situations or places perceived as unsafe, resulting in social isolation. This diagnosis reflects the patient's limited social interactions and confinement to the home environment, which can impact their overall well-being and mental health. The other options are not as relevant in this scenario: 'Ineffective coping' does not directly address the social withdrawal aspect, 'Risk for injury' is not the primary concern presented, and 'Impaired social interaction' does not capture the extent of isolation described.

2. 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.

3. Tomas is a 21-year-old male with a recent diagnosis of schizophrenia. Tomas’s nurse recognizes that self-medicating with excessive alcohol is common in this disease and can co-occur along with:

• A. Generally good health despite the mental illness.
• B. An aversion to drinking fluids.
• C. Anxiety and depression.
• D. The ability to express his needs.

Correct answer: C

Rationale: Individuals with schizophrenia often turn to alcohol as a form of self-medication to manage co-occurring symptoms of anxiety and depression. This coping mechanism can exacerbate the underlying mental health condition and hinder proper treatment. Recognizing and addressing these co-occurring issues are essential in providing holistic care for individuals with schizophrenia.

4. In planning care for the termination phase of a nurse-client relationship, which of the following actions should the nurse include in the plan of care?

• A. Discussing ways to use new behaviors
• B. Practicing new problem-solving skills
• C. Developing goals
• D. Establishing boundaries

Correct answer: A

Rationale: During the termination phase of a nurse-client relationship, it is crucial to discuss ways to use new behaviors. This helps the client integrate and apply the skills and strategies they have acquired during the therapeutic process into their daily life. By focusing on the application of new behaviors, the client can maintain progress and continue to grow even after the professional relationship has ended. Practicing new problem-solving skills, developing goals, and establishing boundaries are important aspects of the therapeutic process but are more commonly addressed in earlier phases of the nurse-client relationship. Therefore, the correct action to include in the plan of care during the termination phase is discussing ways to use new behaviors.

5. Which nursing response provides accurate information to discuss with the female patient diagnosed with bipolar disorder and her support system?

• A. Remember that alcohol and caffeine can trigger a relapse of your symptoms.
• B. Antidepressant therapy should be carefully monitored due to the risk of a manic episode in bipolar disorder.
• C. It’s crucial to inform your healthcare provider promptly if you experience sleep disturbances.
• D. Are your family members prepared to play an active role in helping manage this disorder?

Correct answer: A

Rationale: Choice A is the correct answer as it emphasizes the importance of avoiding triggers like alcohol and caffeine that can lead to symptom relapse in patients with bipolar disorder. Educating the patient and their support system about these triggers is essential for managing the condition effectively and preventing exacerbations of symptoms. Choice B is incorrect as it overly focuses on antidepressant therapy, which is not the primary concern related to triggers for symptom relapse. Choice C, while important, does not directly address triggers for symptom relapse in bipolar disorder. Choice D is also relevant but does not provide immediate information on managing triggers for symptom relapse.

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