Nursing Elites

1. Which of the following is a symptom associated with sensory overload?

• A. Disorientation
• B. Drowsiness
• C. Emotional lability
• D. Depression

Correct answer: A

Rationale: Disorientation is a common symptom associated with sensory overload. When an individual experiences sensory overload, their brain may become overwhelmed with excessive information, leading to disorientation. This can manifest as an inability to concentrate, racing thoughts, and restless behavior. Sensory overload occurs when a person is unable to either control the amount of environmental stimuli they are exposed to or process the stimuli effectively. Drowsiness, emotional lability, and depression are not typical symptoms of sensory overload. Drowsiness may indicate fatigue or boredom, emotional lability refers to rapid and exaggerated changes in mood, and depression is a mood disorder characterized by persistent feelings of sadness and hopelessness.

2. A 37-year-old woman with a history of fibroids and menorrhagia that have not been responsive to hormonal treatments is admitted with severe menorrhagia resulting in anemia. She also has depression and pelvic pain. She is crying and states, 'I don't know what to do"?my primary health care provider is recommending a hysterectomy, but I haven't had children yet!' Which response would the nurse provide?

• A. 'There are so many children up for adoption, looking for a mother.'
• B. 'This must feel so difficult for you. Children are really important to you?'
• C. This must feel so difficult for you. Although Children should not be important to you.'
• D. Believe me when I tell you that kids are so difficult to raise"?you're better off without them.'

Correct answer: B

Rationale: The correct response is to acknowledge the client's feelings and provide an open-ended question to encourage further expression. By expressing empathy and understanding, the nurse can create a supportive environment for the client. This approach allows the client to explore her emotions and concerns freely. Option A, suggesting adoption, may come across as dismissive of the client's current emotional state and may not address her immediate needs. Option D is insensitive and dismissive of the client's feelings and desires regarding having children. It is important to avoid making assumptions or judgments about the client's situation. Option C is a duplicate of Option B, and while it shows empathy, it lacks variety in communication, which may limit the depth of the conversation and the nurse's understanding of the client's needs.

3. A 9-year-old boy is told that he must stay in the hospital for at least 2 weeks. The nurse finds him crying and unwilling to talk. What is the priority nursing care at this time?

• A. Assuring him that his illness is not permanent
• B. Distracting him to prevent further embarrassment
• C. Arranging for him to receive tutoring immediately
• D. Providing privacy to allow him to express his feelings

Correct answer: D

Rationale: The priority nursing care for a 9-year-old child who is crying and unwilling to talk in the hospital is to provide privacy to allow him to express his feelings. Children need an opportunity to express their emotions in private, and talking about their feelings can be therapeutic. Assurances about the illness not being permanent may not be the child's primary concern at this moment. Distracting the child could give the impression that crying is wrong. Arranging tutoring does not address the immediate emotional needs of the child.

4. Which of the following actions is most appropriate when working with a client who is extremely angry?

• A. Place a light hand on the client's shoulder to convey understanding
• B. Maintain close proximity to build trust
• C. Temporarily change the subject if the client's behavior is escalating
• D. Close the door to the room to ensure privacy

Correct answer: C

Rationale: When dealing with an angry client, it is crucial to employ techniques that can help de-escalate the situation or ensure safety while providing care. If the client's behavior is escalating or they are fixating on a particular topic that is fueling their anger, it is advisable to temporarily change the subject. This technique can serve as a distraction from the initial trigger, allowing the client to refocus their thoughts and emotions. Placing a hand on the client's shoulder may not be well-received as physical touch can escalate the situation. Maintaining close proximity might be perceived as confrontational rather than building trust. Closing the door for privacy is important but may not directly address the client's anger or help in de-escalation.

5. Which approach would the healthcare provider use when managing the care of a client diagnosed with generalized anxiety disorder (GAD)?

• A. Creating an anxiety-free environment for the client
• B. Assisting the client with the development of healthy, adaptive coping mechanisms
• C. Avoiding triggers that produce anxiety in the client
• D. Providing reinforcement that the client's anxiety issues can be eliminated

Correct answer: B

Rationale: The healthcare provider would assist the client with the development of healthy, adaptive coping mechanisms. GAD is characterized by the maladaptive use of worrying as a coping mechanism. The ultimate goal is for the healthcare provider to help the client replace the ineffective worrying with effective, healthy coping mechanisms. Creating an anxiety-free environment is not feasible or recommended; the goal is to help the client learn to deal with anxiety in a healthy manner. While identifying triggers is important, avoiding all triggers that produce anxiety is often impractical. Providing reinforcement that anxiety issues can be eliminated is not appropriate as anxiety is a normal human experience that needs to be managed effectively rather than eliminated completely.

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