Nursing Elites

1. Which parameter would be assessed to determine the degree of anxiety being experienced by the client?

• A. Memory state
• B. Creativity level
• C. Perceptual field
• D. Delusional system

Correct answer: C

Rationale: The correct parameter to assess the degree of anxiety experienced by a client is the perceptual field. As anxiety increases, perceptual fields tend to narrow. Memory state, creativity level, and delusional system are not directly related to the level of anxiety and are not appropriate parameters for determining the degree of anxiety. Memory state refers to the ability to remember, creativity level to the ability to generate new ideas or solutions, and delusional system to a set of false beliefs.

2. Which term or description would the nurse use for a client who repeatedly performs ritualistic behaviors throughout the day to limit anxious feelings?

• A. Obsessions
• B. Compulsions
• C. Under personal control
• D. Related to rebelliousness

Correct answer: B

Rationale: The correct answer is 'Compulsions.' A compulsion is an uncontrollable, persistent urge to perform an act repetitively to relieve anxiety. In this scenario, the client's repetitive ritualistic behaviors are indicative of compulsions. Obsessions, on the other hand, are persistent ideas, thoughts, or impulses that cannot be eliminated with logical reasoning. The behavior is not under personal control because avoiding it increases anxiety, making it a defense mechanism. It is not related to rebelliousness; instead, clients engage in these behaviors to reduce anxiety.

3. The mental health nurse plans to discuss a client's depression with the health care provider in the emergency department. There are two clients sitting across from the emergency department desk. Which nursing action is best?

• A. Only refer to the client by gender
• B. Identify the client only by age
• C. Avoid using the client's name
• D. Discuss the client another time

Correct answer: D

Rationale: The best nursing action is to discuss the client another time to ensure confidentiality. It is important to maintain the privacy of the client's information, so discussing sensitive topics like depression in a public area where conversations can be overheard is not appropriate. While options A, B, and C may seem like ways to protect the client's identity, they do not guarantee confidentiality since details like gender or age can still lead to identification. Therefore, the nurse should prioritize privacy and confidentiality by finding a more suitable time and location to have a private discussion about the client's concerns.

4. The nurse selects the best site for insertion of an IV catheter in the client's right arm. Which documentation should the nurse use to identify the placement of the IV access?

• A. Left brachial vein
• B. Right cephalic vein
• C. Dorsal side of the right wrist
• D. Right upper extremity

Correct answer: B

Rationale: The correct answer is the right cephalic vein. The cephalic vein is a large and superficial vein commonly used for IV access. Documenting the specific anatomic name of the vein used for IV access, such as the cephalic vein, is essential for accurate medical records. Option A, the left brachial vein, is incorrect as the brachial vein is too deep to be accessed for IV infusion. Option C, the dorsal side of the right wrist, is not a recommended IV access site due to fragile veins and potential pain for the patient. Option D, right upper extremity, is too broad and lacks the specificity necessary for precise documentation of the IV access site.

5. Your patient has been confused for years. Your patient can be best described as having a chronic ___________ disorder.

• A. physical
• B. psychotic
• C. thinking
• D. palliative

Correct answer: C

Rationale: Patients who experience long-term confusion often have a chronic thinking, or cognitive, disorder. Alzheimer's disease is a prime example of a disorder that results in prolonged confusion and memory loss. Choice A, 'physical', is incorrect as the issue described is related to cognitive functioning, not physical health. Choice B, 'psychotic', refers to a severe mental disorder characterized by a loss of contact with reality, which is not the primary issue presented in the scenario. Choice D, 'palliative', is not relevant as it pertains to specialized medical care for individuals with serious illnesses, focusing on providing relief from symptoms and stress rather than managing chronic confusion.

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