Nursing Elites

1. Under what patient conditions or situations are restraints sometimes used?

• A. As punishment when the patient is uncontrollable
• B. To prevent the patient from pulling their IV out
• C. When a patient is a danger to self and others
• D. Both B and C

Correct answer: D

Rationale: Restraints are sometimes used to prevent a patient from pulling out their IV or another life-saving tube and when the person poses a serious danger to themselves and/or others. Restraints are never used as a form of punishment. Choice A is incorrect because restraints are not utilized for punishment but for patient safety and care. Choice B and C are correct because they reflect the appropriate and necessary situations where restraints may be used in healthcare settings.

2. Which behavioral characteristic describes the domestic abuser?

• A. Alcoholic
• B. Overconfident
• C. High tolerance for frustrations
• D. Low self-esteem

Correct answer: D

Rationale: The correct answer is 'Low self-esteem.' Domestic abusers often exhibit behaviors stemming from their own experiences of abuse, leading to a cycle of violence. They commonly have low self-esteem, which drives their need to exert control and power over their partners. Choice A, 'Alcoholic,' is not a defining behavioral characteristic of domestic abusers. Choice B, 'Overconfident,' is not typically associated with abusers who often exhibit insecurity and control issues. Choice C, 'High tolerance for frustrations,' is not a primary characteristic of domestic abusers; rather, they often have a low tolerance for situations that challenge their need for control.

3. A client says, 'The doctors lied about me. They said I murdered my mother. You killed her. She died before I was born.' Which psychotic feature is the client experiencing?

• A. Ideas of grandeur
• B. Confusing illusions
• C. Persecutory delusions
• D. Auditory hallucinations

Correct answer: C

Rationale: The client is experiencing persecutory delusions, as she believes that others are blaming her for negative actions. This is not about ideas of grandeur, which involve feelings of greatness or power. Confusing illusions refer to misinterpretation of stimuli, which is not present in this scenario. Auditory hallucinations involve hearing voices, which is not the case here. In this case, the client is delusional, but not hallucinating.

4. A client has been diagnosed with depression, and a nurse is assisting them. Which of the following is an example of a short-term outcome as part of the nursing process for this client?

• A. Client will verbalize that depression symptoms have lifted
• B. Client will identify life stressors that may be contributing to depression
• C. Client's insomnia will be resolved as evidenced by 8 hours of sleep each night
• D. Client will identify a mental health counselor in the community with whom they can meet for ongoing therapy

Correct answer: B

Rationale: In the nursing process for a client with depression, short-term outcomes are goals that need to be achieved before advancing towards long-term outcomes. Identifying life stressors that may be contributing to the depression is a crucial initial step. This process helps the client work through feelings of grief or sadness before moving on to long-term goals like therapy and depression management. Choice A is not a short-term outcome as the lifting of depression symptoms is usually a long-term goal. Choice C focuses on resolving insomnia, which is a symptom of depression, but not directly addressing the root cause. Choice D involves identifying a mental health counselor for ongoing therapy, which is more aligned with a long-term treatment plan, rather than a short-term outcome.

5. A client has been diagnosed with a form of terminal cancer and has started receiving hospice care. The nurse notes that both the client and his family avoid talking about the diagnosis. All attempts at discussion result in changing the subject. The nurse recognizes that this family is exhibiting:

• A. Closed awareness
• B. Mutual pretense
• C. Open awareness
• D. Powerless assessment

Correct answer: B

Rationale: The correct answer is 'Mutual pretense.' Mutual pretense is a form of awareness as a response to death or dying in which those involved avoid discussing the situation. In this scenario, both the client and the family are aware of the terminal cancer diagnosis, but they choose not to talk about it openly. This behavior can stem from various reasons, such as trying to shield loved ones from grief, fear of the future, or discomfort with discussing emotions. 'Closed awareness' (Choice A) refers to a lack of awareness of the impending death, which is not the case here. 'Open awareness' (Choice C) involves open acknowledgment and discussion of the terminal illness, which is contrary to the behavior described. 'Powerless assessment' (Choice D) does not relate to the situation of avoiding discussing the diagnosis in the context of terminal cancer and hospice care.

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