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. What is the most appropriate nursing intervention for a client with obsessive-compulsive disorder (OCD) who is constantly washing her hands?

• A. Allow the client to continue washing her hands.
• B. Set limits on the time spent washing her hands.
• C. Encourage the client to wash her hands less frequently.
• D. Assist the client in finding alternative ways to reduce anxiety.

Correct answer: D

Rationale: Assisting the client in finding alternative ways to reduce anxiety is the most appropriate intervention for a client with OCD who is constantly washing her hands. This approach helps address the underlying cause of the compulsive behavior by focusing on reducing anxiety rather than reinforcing the behavior. Allowing the client to continue washing her hands (choice A) would not address the root of the issue and may perpetuate the behavior. Setting limits on the time spent washing hands (choice B) may cause distress to the client and does not address the core problem. Encouraging the client to wash her hands less frequently (choice C) does not provide effective coping strategies for managing anxiety associated with OCD.

3. A client with major depressive disorder is being treated with cognitive-behavioral therapy (CBT). Which client statement indicates that CBT is having a positive effect?

• A. "I understand now that my negative thoughts are not always true."
• B. "I still feel down, but I am able to go to work."
• C. "I have stopped taking my antidepressant medication."
• D. "I avoid situations that make me feel anxious."

Correct answer: A

Rationale: The correct answer is A. Recognizing and challenging negative thoughts is a fundamental aspect of cognitive-behavioral therapy (CBT). In this statement, the client demonstrates insight into the fact that their negative thoughts may not always be accurate, showing progress in reframing their thoughts. Choice B indicates some improvement in functioning but does not directly relate to the core principles of CBT. Choice C is concerning as abruptly stopping antidepressant medication can be detrimental to the client's well-being. Choice D reflects avoidance behavior, which is typically a target for intervention in CBT rather than a sign of positive progress.

4. A nurse is caring for a client with depression who has been prescribed sertraline (Zoloft). The client reports experiencing nausea. What is the nurse's best response?

• A. "You should stop taking the medication immediately."
• B. "Nausea is a common side effect and usually decreases over time."
• C. "Try taking the medication with food to reduce nausea."
• D. "I will inform the healthcare provider to change your medication."

Correct answer: B

Rationale: The correct answer is B: "Nausea is a common side effect of sertraline, and clients should be reassured that it usually decreases as their body adjusts to the medication." Choice A is incorrect because abruptly stopping the medication without consulting a healthcare provider can be harmful. Choice C is a good suggestion to reduce nausea by taking the medication with food but does not address the temporary nature of the side effect. Choice D is unnecessary at this point since nausea is a common side effect that may improve with time.

5. The wife of a male client recently diagnosed with schizophrenia asks the nurse, 'What exactly is schizophrenia? Is my husband all right?' Which response is best for the nurse to provide to this family member?

• A. It sounds like you're worried about your husband. Let's sit down and talk.
• B. It is a chemical imbalance in the brain that causes disorganized thinking.
• C. Your husband will be just fine if he takes his medications regularly.
• D. I think you should talk to your husband's psychologist about this question.

Correct answer: B

Rationale: The best response for the nurse to provide to the wife of the client diagnosed with schizophrenia is to offer factual information. Choice B is the correct answer as it explains that schizophrenia is a mental disorder characterized by a chemical imbalance in the brain that causes disorganized thinking. This response provides a simple and accurate explanation of the condition. Choices A, C, and D are incorrect because they do not directly address the wife's question about what schizophrenia is. Choice A focuses on emotional support rather than providing information about the disorder. Choice C gives false reassurance without addressing the nature of schizophrenia. Choice D deflects the question by suggesting the wife speak to the psychologist, missing an opportunity to educate and support the family member.

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