Nursing Elites

1. Which thought process would the nurse document the mental health client is experiencing after the client says, 'The FBI is out to kill me'?

• A. Hallucinations
• B. Error in judgment
• C. Delusion of persecution
• D. Self-accusatory delusion

Correct answer: C

Rationale: The nurse would document that the client is experiencing a delusion of persecution. A delusion of persecution is a fixed and firm belief of being harassed, in danger, or at the mercy of others, as illustrated by 'The FBI is out to kill me.' Hallucinations are perceived experiences that occur without actual sensory stimulation. Error in judgment refers to poor decision-making, not a distortion of reality like a delusion. A self-accusatory delusion involves accepting blame for an act that was never committed or a feeling that was never acted on. Therefore, the correct choice is 'Delusion of persecution.'

2. 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.

3. The client is a 35-year-old multiparous individual scheduled for a tubal ligation. The nurse assesses the client's emotional response to the planned procedure. Which factor in the client's history will contribute to the healthy resolution of any emotional problem associated with sterilization?

• A. Belief that the surgery will relieve her monthly dysmenorrhea
• B. Knowledge that her partner does not want to have any more children
• C. Feeling that her family is complete and she now has the children she planned for
• D. Recovery from her previous complicated birth and a desire to avoid another birth

Correct answer: C

Rationale: The correct answer is feeling that her family is complete and she now has the children she planned for. Many couples in their 30s who feel that their families are complete choose sterilization as their method of contraception. Sterilization by means of tubal ligation should not be expected to have an effect on dysmenorrhea. The decision to undergo sterilization should be the individual's own choice and should not be influenced by others, including partners. Decisions regarding sterilization should ideally be made when the individual is not under stress, such as after recovery from a previous complicated birth. Therefore, the key factor contributing to a healthy resolution of emotional issues related to sterilization is the feeling of family completeness and achieving the planned number of children.

4. A client undergoing presurgical testing before a total abdominal hysterectomy says to the nurse, 'After I have this surgery I know my husband will never come near me again.' Which response would the nurse give?

• A. You're underestimating how your husband will respond to your surgery.
• B. You're concerned about the effect on your sexual relations.
• C. You're worried that the surgery will change how others see you.
• D. You're concerned about how your husband will respond to your surgery.

Correct answer: D

Rationale: The correct response acknowledges the client's expressed concern about her husband's reaction to the surgery, encouraging further discussion without imposing the nurse's assumptions. Choice A reframes the client's concern to focus on the husband's response, aligning more closely with the client's stated worry. Choice B makes an assumption about the client's concerns regarding sexual relations, which may not be the primary focus of her statement. Choice C shifts the attention to how others perceive the client, deviating from the client's specific reference to her husband's reaction, thus not addressing the client's main concern.

5. The nurse plans care for a hospitalized patient who uses culturally based treatments. Which action by the nurse is best?

• A. Encourage the use of diagnostic procedures.
• B. Coordinate the use of folk treatments with ordered medical therapies.
• C. Ask the patient to discontinue the cultural treatments during hospitalization.
• D. Teach the patient that folk remedies will interfere with orders by the healthcare provider.

Correct answer: B

Rationale: The best action for the nurse is to coordinate the use of folk treatments with ordered medical therapies. Many culturally based therapies can complement Western treatments and medications. It is essential for the nurse to integrate both traditional folk treatments and Western therapies to provide holistic care. Some culturally based treatments can effectively complement Western medicine in treating diseases. Encouraging the patient to continue some culturally based treatments during hospitalization can enhance their overall well-being. Asking the patient to discontinue cultural treatments or teaching that folk remedies interfere with Western therapies may not align with the patient's beliefs and could hinder their care.

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