Nursing Elites

1. Which response would the nurse make to a client with borderline personality disorder who receives the wrong tray for lunch and becomes upset at the dietary staff regarding this mistake?

• A. 'Getting angry is not appropriate; let's address this calmly.''
• B. ''Yelling is not acceptable and won't help us resolve this issue.''
• C. 'You must eat the first tray of food, and then I'll get another tray for you.''
• D. 'It must be frustrating to get the wrong tray. I'll order another tray for you.''

Correct answer: D

Rationale: The most appropriate response from the nurse would be, ''It must be frustrating to get the wrong tray. I'll order another tray for you.'' When interacting with clients with borderline personality disorder, it is crucial for nurses to acknowledge the client's emotions empathetically and provide constructive solutions. While expressing anger is understandable, guiding the client towards a more constructive approach is essential. Yelling is not a helpful way to address the situation and threatening seclusion is inappropriate. Additionally, instructing the client to eat the first tray before receiving another one is punitive and disregards the client's preferences and rights.

2. A client admitted with a diagnosis of cervical cancer tells the nurse, 'I haven't had a Papanicolaou (Pap) smear for more than 8 years. I probably wouldn't be in the hospital today if I'd had those tests more often.' Which response would the nurse provide?

• A. ''Please tell me why you waited so long.''
• B. 'You feel as though you've neglected your health.''
• C. 'It's never too late to start taking care of yourself.''
• D. 'Most women hate to have Pap smears done, but they're really important.''

Correct answer: B

Rationale: The correct response, ''You feel as though you've neglected your health,'' is appropriate as it indicates recognition of expressed feelings, encouraging verbalization. This response is nondirective and reflective. Choice A, asking the client why she waited so long, ignores the client's current emotional needs and may cut off communication. Choice C, stating that it is never too late to start taking care of her health, is judgmental as it implies that the client has been negligent. Choice D, although acknowledging the importance of Pap smears, fails to address the client's current emotional state and needs.

3. When doing an admission assessment for a patient, the nurse notices that the patient pauses before answering questions about the health history. Which action by the nurse is most appropriate?

• A. Interview a family member instead.
• B. Wait for the patient to answer the questions.
• C. Remind the patient that you have other patients who need care.
• D. Give the patient an assessment form listing the questions and a pen.

Correct answer: B

Rationale: When a patient pauses before answering questions about their health history, it is important for the nurse to be patient and wait for the patient to answer the questions. Patients from different cultures may take time to consider a question carefully before responding. By waiting patiently, the nurse shows respect for the patient's pace and helps foster a trusting relationship. Asking a family member to answer instead may not provide accurate information from the patient themselves. Reminding the patient about other patients needing care could make the patient feel rushed or unimportant. Giving the patient an assessment form and pen does not address the underlying reason for the pause and may come across as dismissive of the patient's need for time to respond thoughtfully.

4. A client with generalized anxiety disorder presents with restlessness and fatigue. Which additional clinical manifestation would the nurse monitor for?

• A. Hoarding
• B. Panic attacks
• C. Excessive worry
• D. Fear of leaving the house

Correct answer: C

Rationale: The nurse would monitor for excessive worry. Generalized anxiety disorder is characterized by physical and cognitive symptoms of chronic or excessive anxiety and worry. Excessive worry is a core feature of generalized anxiety disorder. Hoarding is a symptom of hoarding disorder, not generalized anxiety disorder. Panic attacks are typical of panic disorder, not generalized anxiety disorder. Fear of leaving the house is a characteristic of agoraphobia, which is distinct from generalized anxiety disorder.

5. 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.

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