Nursing Elites

1. Tatiana has been hospitalized for an acute manic episode. On admission, the nurse suspects lithium toxicity. What assessment findings would indicate the nurse's suspicion as correct?

• A. Shortness of breath, gastrointestinal distress, chronic cough
• B. Ataxia, severe hypotension, large volume of dilute urine
• C. Gastrointestinal distress, thirst, nystagmus
• D. Electroencephalographic changes, chest pain, dizziness

Correct answer: B

Rationale: The correct answer is B. Ataxia, severe hypotension, and a large volume of dilute urine are classic signs of lithium toxicity. Ataxia refers to a lack of muscle coordination, severe hypotension indicates dangerously low blood pressure, and the large volume of dilute urine is a result of the kidneys' inability to concentrate urine properly, a common feature of lithium toxicity.

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

• A. Encourage the client to express feelings about the hallucinations.
• B. Distract the client from the hallucinations.
• C. Provide reality-based feedback about the hallucinations.
• D. Encourage the client to ignore the hallucinations.

Correct answer: C

Rationale: The correct intervention for a client experiencing auditory hallucinations in schizophrenia is to provide reality-based feedback about the hallucinations. By providing reality-based feedback, the nurse helps the client differentiate between what is real and what is not, which can help decrease the distress and impact of the hallucinations on the client's perception of reality. Encouraging the client to express feelings (Choice A) may not directly address the hallucinations. Distracting the client (Choice B) may temporarily alleviate the symptoms but does not help the client differentiate reality from hallucinations. Encouraging the client to ignore the hallucinations (Choice D) may not be effective as the client may struggle to do so without appropriate guidance.

3. Which client statement should alert a nurse that a client may be responding maladaptively to stress?

• A. I've found that avoiding contact with others helps me cope.
• B. I really enjoy journaling; it's my private time.
• C. I signed up for a yoga class this week.
• D. I made an appointment to meet with a therapist.

Correct answer: A

Rationale: The correct answer is A. Reliance on social isolation as a coping mechanism is maladaptive and can hinder the development of appropriate coping skills and access to support systems. It may indicate a lack of healthy coping strategies and social connections, which are important for managing stress effectively. Choice B is a positive coping strategy that promotes self-reflection and emotional expression. Choice C reflects a proactive approach to managing stress through physical activity. Choice D shows a willingness to seek professional help, which is a healthy coping mechanism.

4. A healthcare professional is teaching a patient about relaxation techniques to manage anxiety. Which technique is the healthcare professional most likely to recommend?

• A. Deep breathing exercises
• B. Physical exercise
• C. Mindfulness meditation
• D. Journaling

Correct answer: A

Rationale: Deep breathing exercises are a widely recommended technique for managing anxiety and promoting relaxation. By focusing on deep, slow breaths, individuals can activate the body's relaxation response, leading to decreased anxiety levels and an overall sense of calm. This technique is easy to learn, can be practiced anywhere, and is often suggested by healthcare professionals as a first-line approach for anxiety management. Physical exercise, mindfulness meditation, and journaling are also beneficial for mental well-being but may not be the first choice when specifically targeting acute anxiety management.

5. Which intervention focuses on managing a common characteristic of major depressive disorder associated with the older population?

• A. Conducting routine suicide screenings at a senior center.
• B. Identifying depression as a natural, but treatable outcome of aging.
• C. Identifying males as at a greater risk for developing depression.
• D. Stressing that most individuals experience only a single episode of major depression in a lifetime.

Correct answer: A

Rationale: Conducting routine suicide screenings at senior centers is crucial in managing major depressive disorder in the older population. Screening helps identify individuals at risk, allows for timely intervention, and contributes to the overall well-being of older adults.

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