Nursing Elites

1. James is a 42-year-old patient with schizophrenia. He approaches you as you arrive for the day shift and anxiously reports, 'Last night, demons came to my room and tried to rape me.' Which response would be most therapeutic?

• A. There are no such things as demons. What you saw were hallucinations.
• B. It is not possible for anyone to enter your room at night. You are safe here.
• C. You seem very upset. Please tell me more about what you experienced last night.
• D. That must have been very frightening, but we'll check on you at night and you'll be safe.

Correct answer: C

Rationale: Response C is the most therapeutic as it shows empathy and encourages the patient to express their feelings and share more about their experience. By actively listening and inviting the patient to talk, the nurse creates a supportive environment that can help the patient feel heard and understood, which is essential in building trust and rapport in therapeutic communication with individuals experiencing schizophrenia.

2. A patient with schizophrenia is prescribed clozapine. Which potential side effect requires regular monitoring?

• A. Weight loss
• B. Hypertension
• C. Agranulocytosis
• D. Hyperthyroidism

Correct answer: C

Rationale: When a patient with schizophrenia is prescribed clozapine, regular monitoring for agranulocytosis is essential. Agranulocytosis is a severe reduction in white blood cells that can be life-threatening. Monitoring white blood cell counts is crucial to detect this side effect early and prevent serious complications. Weight loss (Choice A) is not a common side effect of clozapine. Hypertension (Choice B) and hyperthyroidism (Choice D) are also not typically associated with clozapine use, making them incorrect choices for regular monitoring.

3. A client diagnosed with post-traumatic stress disorder (PTSD) is being assessed by a healthcare professional. Which symptom would the healthcare professional expect the client to exhibit?

• A. Delusions of grandeur
• B. Hypervigilance
• C. Obsessive-compulsive behaviors
• D. Periods of excessive sleeping

Correct answer: B

Rationale: In individuals with post-traumatic stress disorder (PTSD), hypervigilance is a common symptom. Hypervigilance refers to a state of increased alertness, awareness, and sensitivity to potential threats or danger. This heightened state of vigilance can manifest as being easily startled, having difficulty relaxing or sleeping, and constantly scanning the environment for signs of danger. It is an adaptive response to the trauma experienced and can significantly impact the individual's daily functioning. The other options are not typically associated with PTSD. Delusions of grandeur are more commonly seen in certain psychiatric disorders like bipolar disorder or schizophrenia. Obsessive-compulsive behaviors are characteristic of obsessive-compulsive disorder (OCD), not PTSD. Periods of excessive sleeping may be seen in conditions like depression, but they are not a hallmark symptom of PTSD.

4. In a center for women who have been abused, which intervention would the nurse use for a woman whose husband has been abusing her for several years?

• A. Often times you don't need help, you just need to know when to go
• B. Under these circumstances, leaving your husband is the decision to make
• C. This must be very painful for you. We are here to help you
• D. Let's talk about your strengths. You have them, but sometimes they get lost in pain

Correct answer: C

Rationale: Choice C is the most appropriate intervention when working with a woman who has been abused by her husband. It acknowledges the woman's pain, expresses empathy, and offers support, creating a safe space for her to open up and seek help. This response shows understanding and compassion, which are crucial when dealing with individuals experiencing abuse.

5. A client with obsessive-compulsive disorder (OCD) is being cared for by a nurse. Which intervention should the nurse implement to help the client manage compulsive behaviors?

• A. Encourage the client to suppress compulsive behaviors.
• B. Allow the client to perform compulsive behaviors with limits.
• C. Teach the client relaxation techniques to manage anxiety.
• D. Discourage the client from performing compulsive behaviors.

Correct answer: B

Rationale: Allowing the client to perform compulsive behaviors with limits is a therapeutic intervention for managing OCD. This approach grants the client some autonomy while ensuring that the behaviors do not excessively disrupt daily life. Setting boundaries helps structure the behaviors, decreasing anxiety and distress associated with OCD. Encouraging the client to suppress compulsive behaviors (choice A) may lead to increased anxiety and potential worsening of symptoms. Teaching relaxation techniques (choice C) is beneficial for managing anxiety in general but may not directly address the compulsive behaviors. Discouraging the client from performing compulsive behaviors (choice D) without providing alternative strategies or support may increase distress and resistance.

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