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 nurse working on a mental health unit receives a community call from a person who is tearful and states, 'I just feel so nervous all of the time. I don't know what to do about my problems. I haven't been able to sleep at night and have hardly eaten for the past 3 or 4 days.' The nurse should initiate a referral based on which assessment?

• A. Altered thought processes.
• B. Moderate levels of anxiety.
• C. Inadequate social support.
• D. Altered health maintenance.

Correct answer: B

Rationale: The nurse should initiate a referral based on moderate levels of anxiety (B) as the client reports feeling nervous all the time, sleep disturbances, poor appetite, and difficulty solving problems. These symptoms are indicative of significant anxiety levels. The client does not mention symptoms related to altered thought processes (A) or inadequate social support (C). There is insufficient information to suggest altered health maintenance (D) as a reason for referral in this scenario.

3. A female client on a psychiatric unit is sweating profusely while she vigorously does push-ups and then runs the length of the corridor several times before crashing into furniture in the sitting room. Picking herself up, she begins to toss chairs aside, looking for a red one to sit in. When another client objects to the disturbance, the client shouts, 'I am the boss here. I do what I want.' Which nursing problem best supports these observations?

• A. Deficient diversional activity related to excess energy level.
• B. Risk for other-directed violence related to disruptive behavior.
• C. Risk for activity intolerance related to hyperactivity.
• D. Disturbed personal identity related to grandiosity.

Correct answer: B

Rationale: The client's disruptive and potentially harmful behavior, including tossing chairs and claiming authority, indicates a risk for other-directed violence. This behavior poses a threat to the safety of the client and others. While the client may have excess energy, the primary concern is the potential for violence, not just a lack of diversional activities (Choice A). The client's behavior is not solely due to hyperactivity leading to activity intolerance (Choice C) or grandiosity affecting personal identity (Choice D), making these options less appropriate in this context.

4. A 35-year-old male client on the psychiatric unit of a general hospital believes that someone is trying to poison him. The nurse understands that a client's delusions are most likely related to his

• A. early childhood experiences involving authority issues.
• B. anger about being hospitalized.
• C. low self-esteem.
• D. phobic fear of food.

Correct answer: C

Rationale: Psychotic clients often experience delusions due to difficulties with trust and low self-esteem (C). In this case, the client's belief that someone is trying to poison him is likely a manifestation of his underlying issues with trust and self-worth. Building trust and promoting positive self-esteem are essential in caring for such clients. Choices A, B, and D are incorrect because delusions are not primarily related to early childhood experiences involving authority issues, anger about hospitalization, or phobic fear of food. These factors do not directly contribute to the development of delusions in psychotic clients.

5. A woman arrives in the Emergency Center and tells the nurse she thinks she has been raped. The client is sobbing and expresses disbelief that a rape could happen because the man is her best friend. After acknowledging the client's fear and anxiety, how should the nurse respond?

• A. I would be very upset and mad if my best friend did that to me.
• B. You must feel betrayed, but maybe you might have led him on?
• C. Rape is not limited to strangers and frequently occurs by someone who is known to the victim.
• D. This does not sound like rape. Did you change your mind about having sex after the fact?

Correct answer: C

Rationale: A victim of date rape or acquaintance rape is less prone to recognize what is happening because the incident usually involves persons who know each other and the dynamics are different than rape by a stranger. Choice (C) provides confrontation for the client's denial because the victim frequently knows and trusts the perpetrator. Nurses should not express personal feelings (Choice A) when dealing with victims. Choice B, suggesting that the client led on the rapist, indicates that the sexual assault was somehow the victim's fault. Choice D is judgmental and does not display compassion or establish trust between the nurse and the client.

Similar Questions