Nursing Elites

1. An antidepressant medication is prescribed for a client who reports sleeping only 4 hours in the past 2 days and weight loss of 9 lbs within the last month. Which client goal is most important to achieve within the first three days of treatment?

• A. Meet scheduled appointments with a dietitian.
• B. Sleep at least 6 hours a night.
• C. Understand the purpose of the medication regimen.
• D. Describe the reasons for hospitalization.

Correct answer: B

Rationale: The most important goal to achieve within the first three days of treatment is to ensure the client can sleep at least 6 hours a night. Adequate sleep is essential for stabilizing mood and improving overall functioning. Improving sleep patterns is crucial to address the reported sleep deficit and weight loss associated with depression. Choice A is not as urgent as improving sleep patterns. Choice C is important but not as immediate as addressing the sleep deficit. Choice D is unrelated to the immediate treatment goal of improving sleep and managing symptoms of depression.

2. An elderly client is admitted to the psychiatric unit with a diagnosis of major depressive disorder. Which assessment finding is most concerning for the nurse?

• A. Weight loss of 5 pounds in one week.
• B. Lack of interest in previously enjoyed activities.
• C. Disorganized speech and thought processes.
• D. Severe fatigue and low energy levels.

Correct answer: C

Rationale: In an elderly client with major depressive disorder, disorganized speech and thought processes are the most concerning assessment findings for the nurse. These symptoms can suggest a more severe condition such as psychosis or cognitive impairment, which require immediate attention and intervention. While weight loss, lack of interest in activities, severe fatigue, and low energy levels are common symptoms of major depressive disorder, they do not pose an immediate risk as disorganized speech and thought processes do. Therefore, the nurse should prioritize addressing the disorganized speech and thought processes to ensure the safety and well-being of the client.

3. A male client approaches the nurse with an angry expression on his face and raises his voice, saying, “My roommate is the most selfish, self-centered, angry person I have ever met. If he loses his temper one more time with me, I am going to punch him out!” The nurse recognizes that the client is using which defense mechanism?

• A. Denial
• B. Projection
• C. Rationalization
• D. Splitting

Correct answer: B

Rationale: The correct answer is B: Projection. In this scenario, the client is projecting his own feelings of anger onto his roommate by attributing his anger to the roommate. Projection involves shifting one's feelings, thoughts, or impulses onto another person. Denial (choice A) is the refusal to accept reality, Rationalization (choice C) involves justifying behaviors with logical reasons, and Splitting (choice D) is the inability to integrate positive and negative qualities of oneself or others.

4. A teenager who has lost 20 pounds in the last three months is admitted to the hospital with hypotension and tachycardia. The client reports irregular menses and hair loss. Which intervention is most important for the nurse to include in the client plan of care?

• A. Implement behavior modification therapy.
• B. Initiate caloric and nutritional therapy.
• C. Evaluate the client for low self-esteem.
• D. Record daily weights and graph trends.

Correct answer: B

Rationale: Initiating caloric and nutritional therapy is the most important intervention for this client due to the significant weight loss and presenting symptoms of hypotension, tachycardia, irregular menses, and hair loss. This intervention aims to address the physical effects of malnutrition and support the client's overall health. Behavior modification therapy (Choice A) may be beneficial in the long term to address underlying issues, but addressing the immediate nutritional needs is a priority. Evaluating the client for low self-esteem (Choice C) is important for holistic care but addressing the physical health concerns takes precedence. Recording daily weights and graphing trends (Choice D) is essential for monitoring progress but does not address the urgent need for nutritional support in this acute situation.

5. The nurse completes an assessment of a client who is experiencing intimate partner violence (IPV). Which finding of the injuries should the nurse include in the documentation?

• A. The client’s significant other’s statement.
• B. Photographs.
• C. General description.
• D. A summary of the client’s feelings.

Correct answer: B

Rationale: In cases of intimate partner violence (IPV), documenting injuries is essential for legal and medical purposes. Photographs provide concrete and objective evidence of the injuries, leaving no room for interpretation or doubt. This visual documentation can be crucial in legal proceedings and serve as a critical component in ensuring the safety and well-being of the client. The significant other's statement (Choice A) may not accurately reflect the client's injuries and could be biased. A general description (Choice C) lacks the specificity and objectivity that photographs offer. Summarizing the client's feelings (Choice D) is important for emotional support but does not provide the concrete evidence needed in documenting IPV cases.

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