Nursing Elites

1. During a mental status exam, what factor should the nurse remember when assessing a client's intelligence?

• A. Acute psychiatric illnesses can impair intelligence
• B. Intelligence can be influenced by social and cultural beliefs
• C. Poor concentration skills suggest limited intelligence
• D. The inability to think abstractly indicates limited intelligence

Correct answer: B

Rationale: The correct answer is B. Intelligence is indeed influenced by social and cultural beliefs. It is essential to recognize that intelligence is not solely determined by innate abilities but can also be shaped by various external factors such as cultural background, education, and social environment. Choices A, C, and D are incorrect because acute psychiatric illnesses do not necessarily impair intelligence, poor concentration skills do not always suggest limited intelligence, and the inability to think abstractly alone does not always indicate limited intelligence.

2. A female client with post-traumatic stress disorder (PTSD) has been experiencing flashbacks. Which intervention should the nurse implement to help the client?

• A. Encourage the client to talk about the trauma.
• B. Advise the client to avoid triggers that cause flashbacks.
• C. Help the client stay grounded in the present moment.
• D. Refer the client to group therapy for PTSD.

Correct answer: C

Rationale: The correct intervention for a client with PTSD experiencing flashbacks is to help them stay grounded in the present moment. This technique can reduce the intensity of flashbacks and provide a sense of safety. Encouraging the client to talk about the trauma (Choice A) may exacerbate the symptoms and should be done cautiously under professional guidance. Advising the client to avoid triggers (Choice B) is important, but solely relying on avoidance may not address the underlying issues. Referring the client to group therapy (Choice D) can be beneficial, but in the immediate context of managing flashbacks, grounding techniques are more appropriate.

3. An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12 days. Which assessment finding requires immediate follow-up?

• A. Describes life as without purpose.
• B. Exhibits an increase in sweating.
• C. States is often fatigued and drowsy.
• D. Complains of nausea and loss of appetite.

Correct answer: A

Rationale: The correct answer is A. Expressing that life is without purpose can indicate deepening depression or suicidal ideation, which requires immediate attention. While sweating, fatigue, drowsiness, nausea, and loss of appetite can be side effects of duloxetine (Cymbalta), they do not indicate the same level of urgency as a statement suggesting deepening depression or suicidal ideation.

4. A female victim of sexual assault is being seen in the crisis center. The client states that she still feels 'as though the rape just happened yesterday,' even though it has been a few months since the incident. The appropriate nursing response is which of the following?

• A. You need to try to be realistic. The rape did not just occur.
• B. It will take some time to get over these feelings about your rape.
• C. Tell me more about the incident that causes you to feel like the rape just occurred.
• D. What do you think you can do to alleviate some of your fears about being raped again?

Correct answer: C

Rationale: The correct response is to encourage the client to talk about the event that makes them feel as though the rape just occurred. This approach can help the client process their feelings and experiences, which is crucial in dealing with trauma. Choice A is dismissive and negates the client's feelings, which can be harmful. Choice B, although acknowledging the time needed to heal, does not actively address the client's current feelings. Choice D shifts the focus to future fears rather than addressing the client's current emotional state.

5. What is the most important goal of care for a client diagnosed with generalized anxiety disorder (GAD) who has been taking the benzodiazepine alprazolam (Xanax) long-term? The client will:

• A. Describe a decrease in anxiety using a 1 to 10 anxiety scale.
• B. State the importance of not abruptly stopping the medication.
• C. Not experience dizziness, lightheadedness, or sedation.
• D. Attend scheduled individual and group therapy sessions.

Correct answer: B

Rationale: The correct answer is B. The most important goal of care for a client with generalized anxiety disorder (GAD) taking alprazolam long-term is to ensure they understand the importance of not abruptly stopping the medication. Abruptly stopping benzodiazepines can lead to withdrawal symptoms and potential complications. Choice A is not the most critical goal as the focus should be on the safe continuation of the medication. Choice C is important but not as crucial as preventing abrupt discontinuation. Choice D is beneficial for overall treatment but not the most important goal in this scenario.

Similar Questions