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. At a support meeting of parents of a teenager with polysubstance dependency, a parent states, 'Each time my son tries to quit taking drugs, he gets so depressed that I'm afraid he will commit suicide.' The nurse's response should be based on which information?

• A. Addiction is a chronic, incurable disease
• B. Tolerance to the effects of drugs causes feelings of depression
• C. Feelings of depression frequently lead to drug abuse and addiction
• D. Careful monitoring should be provided during withdrawal from the drugs

Correct answer: D

Rationale: The priority is to teach the parents that their son will need monitoring and support during withdrawal to ensure that he does not attempt suicide. Option A is incorrect because addiction can be managed and treated effectively with appropriate interventions. Option B is incorrect as tolerance to drugs causing depression is not the primary concern in this scenario. Option C is incorrect as while depression can be a risk factor for drug abuse, in this case, the focus is on the son's safety during withdrawal.

3. A 22-year-old male client is admitted to the emergency center following a suicide attempt. His records reveal that this is his third suicide attempt in the past two years. He is conscious, but does not respond to verbal commands for treatment. Which assessment finding should prompt the nurse to prepare the client for gastric lavage?

• A. He ingested the drug 3 hours prior to admission to the emergency center.
• B. The family reports that he took an entire bottle of acetaminophen (Tylenol).
• C. He is unresponsive to instructions and is unable to cooperate with emetic therapy.
• D. Those with repeated suicide attempts desire punishment to relieve their guilt.

Correct answer: C

Rationale: The correct answer is C because the client's unresponsiveness to instructions and inability to cooperate with emetic therapy would make it challenging to implement such therapy effectively. In such cases, gastric lavage may be necessary to remove the ingested substance. Choices A and B are important considerations in treatment planning but do not directly indicate the need for gastric lavage. Choice D is incorrect as medical treatments should never be used as punitive measures but rather for therapeutic purposes.

4. What assessment is the priority focus for a client with major depression?

• A. Mood and affect.
• B. Suicidal ideation.
• C. Nutritional status.
• D. Fluid and electrolyte balance.

Correct answer: B

Rationale: The correct answer is B: Suicidal ideation. When dealing with a client diagnosed with major depression, assessing for suicidal ideation is of utmost importance. Individuals with major depression have an increased risk of suicide; hence, evaluating their risk for self-harm is crucial. Mood and affect, while important, come secondary to ensuring the safety of the client. Nutritional status and fluid and electrolyte balance are essential components of care but are not the priority when dealing with a client with major depression.

5. A middle-aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and low motivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning?

• A. Provide education on methods to enhance sleep.
• B. Teach the client to develop a plan for daily structured activities.
• C. Suggest that the client develop a list of pleasurable activities.
• D. Encourage the client to exercise.

Correct answer: B

Rationale: Teaching the client to develop a plan for daily structured activities is the most effective intervention in this case. Creating a routine can help improve motivation and provide a sense of accomplishment, aiding in the recovery process. Option A, providing education on methods to enhance sleep, may address hypersomnia but does not directly target psychomotor retardation and low motivation. Option C, suggesting the client develop a list of pleasurable activities, may not address the need for structure and routine. Option D, encouraging the client to exercise, is beneficial but may not be as effective as creating a structured daily plan to address the client's specific symptoms.

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