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. Which therapeutic communication technique is being used when the nurse says, 'Tell me more about what you are feeling right now'?

• A. Restating
• B. Clarification
• C. Reflection
• D. Exploration

Correct answer: D

Rationale: The correct answer is D, Exploration. In this scenario, the nurse is using the exploration technique to encourage the patient to elaborate further on their feelings. Exploration involves prompting the patient to delve deeper into their thoughts and emotions, fostering a more comprehensive discussion and understanding of their experiences.

3. A patient with posttraumatic stress disorder (PTSD) is experiencing flashbacks. What is the most appropriate initial nursing intervention?

• A. Encourage the patient to talk briefly about the traumatic event.
• B. Reassure the patient that they are safe and the event is not happening now.
• C. Administer a sedative medication as prescribed.
• D. Suggest the patient write about their feelings in a journal.

Correct answer: B

Rationale: During a flashback, the patient may feel as though the traumatic event is reoccurring. Reassuring the patient that they are safe and the event is not happening presently can help ground them in reality and reduce anxiety. This approach can provide a sense of safety and security, which is crucial in managing flashbacks associated with PTSD. Encouraging the patient to talk briefly about the traumatic event may worsen the distress during a flashback by intensifying the re-experiencing of the trauma. Administering sedative medication should not be the initial intervention, as non-pharmacological approaches are preferred in managing flashbacks. Suggesting the patient write about their feelings in a journal may be beneficial as part of ongoing therapy, but it is not the most appropriate initial intervention during a flashback.

4. During a mental health assessment, a patient states, 'I just don't see the point in anything anymore.' This statement is an indication of which of the following?

• A. Anxiety disorder
• B. Bipolar disorder
• C. Depression
• D. Schizophrenia

Correct answer: C

Rationale: The patient's statement 'I just don't see the point in anything anymore' reflects feelings of hopelessness and a lack of purpose, which are common symptoms of depression. Depression is characterized by persistent feelings of sadness, emptiness, and loss of interest or pleasure in activities that were once enjoyable. While anxiety disorders can involve excessive worry and fear, bipolar disorder includes episodes of both depression and mania, and schizophrenia typically involves symptoms such as hallucinations and delusions. Therefore, depression is the most appropriate choice based on the patient's statement.

5. When a patient is diagnosed with major depressive disorder, which nursing diagnosis should be the priority?

• A. Imbalanced nutrition: less than body requirements
• B. Risk for suicide
• C. Disturbed sleep pattern
• D. Ineffective coping

Correct answer: B

Rationale: The priority nursing diagnosis for a patient diagnosed with major depressive disorder is 'Risk for suicide.' This is the priority as it addresses the immediate risk of self-harm in individuals suffering from major depressive disorder. Monitoring and intervening to prevent self-harm take precedence over other nursing diagnoses in this scenario.

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