Nursing Elites

1. At what point should the nurse determine that a client is at risk for developing a mental disorder?

• A. When thoughts, feelings, and behaviors are not reflective of the DSM-5 criteria
• B. When maladaptive responses to stress are coupled with interference in daily functioning
• C. When the client communicates significant distress
• D. When the client uses defense mechanisms as ego protection

Correct answer: B

Rationale: The nurse should determine that the client is at risk for mental disorder when responses to stress are maladaptive and interfere with daily functioning. The DSM-5 indicates that in order to be diagnosed with a mental disorder, there must be significant disturbance in cognition, emotion, regulation, or behavior that reflects a dysfunction in the psychological, biological or developmental processes underlying mental functioning. These disorders are usually associated with significant distress or disability in social, occupational, or other important activities. The client's ability to communicate distress would be considered a positive attribute.

2. During an acute panic attack, which intervention should the nurse implement?

• A. Encourage the client to discuss their feelings
• B. Provide a calm environment
• C. Teach the client deep breathing exercises
• D. Leave the client alone to calm down

Correct answer: C

Rationale: During an acute panic attack, the priority intervention is to create a calm and safe environment. Teaching the client deep breathing exercises is crucial as it promotes relaxation and reduces hyperventilation, helping to manage the panic attack effectively. Encouraging the client to discuss their feelings may exacerbate the panic by increasing emotional distress. Providing a busy environment can escalate stress levels rather than alleviate them. Leaving the client alone may lead to feelings of abandonment or worsen the panic attack. Therefore, the most appropriate intervention is to teach deep breathing exercises to help the client regain control and manage the panic attack.

3. A client with schizophrenia is experiencing auditory hallucinations. Which intervention should the nurse implement to address this symptom?

• A. Encourage the client to discuss the voices.
• B. Tell the client that the voices are not real.
• C. Provide reality-based feedback to the client.
• D. Distract the client from the voices.

Correct answer: C

Rationale: When a client with schizophrenia is experiencing auditory hallucinations, providing reality-based feedback is a therapeutic intervention. This helps the client differentiate between what is real and what is not, aiding in reducing the impact of hallucinations. Encouraging the client to discuss the voices may validate the hallucinations, telling the client that the voices are not real dismisses their experience, and distracting the client may not address the underlying issue of the hallucinations.

4. A client is experiencing progressive changes in memory that have interfered with personal, social, and occupational functioning. The client exhibits poor judgment and has a short attention span. The nurse recognizes these as classic signs of which condition?

• A. Delirium
• B. Mania
• C. Parkinsonism
• D. Alzheimer’s

Correct answer: D

Rationale: The client's presentation of progressive memory changes, poor judgment, and attention deficits align with classic signs of Alzheimer's disease. Alzheimer's is a neurodegenerative disorder characterized by cognitive decline that significantly impacts daily functioning. While delirium and mania may present with cognitive changes, Alzheimer's is specifically associated with progressive memory loss and cognitive impairment over time.

5. A client diagnosed with panic disorder is receiving discharge teaching from a healthcare provider. Which statement by the client indicates an accurate understanding of the teaching?

• A. I should avoid caffeine and other stimulants.
• B. I should take my medication only when I feel anxious.
• C. I should use relaxation techniques to manage anxiety.
• D. I should avoid exercising to prevent triggering anxiety.

Correct answer: A

Rationale: The correct answer is A. Avoiding caffeine and other stimulants is crucial for clients with panic disorder as these substances can exacerbate anxiety symptoms. Caffeine can trigger or worsen anxiety, leading to increased heart rate and restlessness. By eliminating stimulants, the client can better manage their anxiety levels and reduce the risk of panic attacks. Choices B, C, and D are incorrect because taking medication only when feeling anxious may lead to inconsistent treatment, using relaxation techniques alone may not be sufficient for managing panic disorder, and avoiding exercise can actually be counterproductive as regular physical activity can help reduce anxiety and stress levels.

Similar Questions