Nursing Elites

1. 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.

2. A middle-aged female client with no previous psychiatric history is seen in the mental health clinic because her family describes her as having paranoid thoughts. On assessment, she tells the nurse, “I want to find out why these people are stalking me.” Which response should the nurse provide?

• A. It sounds like this experience is frightening for you.
• B. What makes you think people are stalking you?
• C. I know you are frightened, but no one is stalking you.
• D. Do you think someone is trying to harm you?

Correct answer: A

Rationale: The correct response for the nurse to provide is option A: 'It sounds like this experience is frightening for you.' This response acknowledges the client's feelings and emotions without directly challenging the delusion of being stalked. Option B is incorrect as it directly questions the client's belief, which can lead to increased defensiveness. Option C is incorrect as it denies the client's belief without addressing the underlying fear and can cause the client to feel misunderstood. Option D is incorrect as it directly asks about harm, which may not be the primary concern of the client at this moment.

3. A healthcare professional is preparing to provide medication education to a client who has just been prescribed an antipsychotic medication. What should the healthcare professional include in the teaching plan?

• A. “You should have regular eye exams.”
• B. “It is important to avoid caffeine while on this medication.”
• C. “You may experience dry mouth and blurred vision.”
• D. “You should increase your intake of vitamin C to prevent side effects.”

Correct answer: C

Rationale: The correct answer is C. Antipsychotic medications often have anticholinergic side effects like dry mouth and blurred vision. Teaching the client about these potential side effects is essential for their understanding and management. Regular eye exams (Choice A) are not specifically related to antipsychotic medications. While avoiding caffeine (Choice B) might be a general good practice, it is not a specific side effect of antipsychotic medications. Increasing vitamin C intake (Choice D) is not a standard recommendation for preventing antipsychotic medication side effects.

4. An adolescent with anorexia nervosa is undergoing nutritional therapy. Which finding best indicates that the client is making progress in treatment?

• A. Client gains 2 pounds in a week.
• B. Client describes a positive body image.
• C. Client engages in recreational activities.
• D. Client begins to talk about future goals.

Correct answer: A

Rationale: The correct answer is A. Weight gain is a crucial indicator of progress in the treatment of anorexia nervosa. In individuals with anorexia, restoring and maintaining a healthy weight is a primary goal to address the underlying nutritional deficiencies and health complications associated with the disorder. While choices B, C, and D are positive developments in the client's overall well-being and recovery journey, they are not as directly linked to the core issue of nutritional rehabilitation in anorexia nervosa. Describing a positive body image, engaging in recreational activities, and talking about future goals are important aspects of psychological and emotional recovery, but weight gain is a more immediate and objective measure of progress in treating anorexia nervosa.

5. The nurse is completing the admission assessment of an underweight adolescent admitted to the psychiatric unit with a diagnosis of depression. Which finding requires notification to the healthcare provider?

• A. Body mass index of 21
• B. Potassium level of 2.9 mEq/dL
• C. WBC count of 10,000/mm3
• D. Blood pressure of 110/70 mmHg

Correct answer: B

Rationale: The correct answer is B. A potassium level of 2.9 mEq/dL is critically low and requires immediate notification to the healthcare provider as it indicates a potential electrolyte imbalance, which can lead to serious cardiac arrhythmias and other complications. Choices A, C, and D are within normal ranges or not indicative of immediate life-threatening issues. A body mass index of 21 may be considered normal for some individuals, a WBC count of 10,000/mm3 is slightly elevated but not an urgent concern, and a blood pressure of 110/70 mmHg is within normal limits for an adolescent.

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