Nursing Elites

1. A 52-year-old male client in the intensive care unit who has been oriented suddenly becomes disoriented and fearful. Assessment of vital signs and other physical parameters reveal no significant change, and the nurse formulates the diagnosis, 'Confusion related to ICU psychosis.' Which intervention would be best to implement?

• A. Move all machines away from the client's immediate area.
• B. Attempt to allay the client's fears by explaining the etiology of his condition.
• C. Cluster care so that brief periods of rest can be scheduled during the day.
• D. Extend visitation times for family and friends.

Correct answer: C

Rationale: In critical care environments, stressors can lead to isolation and confusion. Providing the client with scheduled rest periods (C) can help alleviate these symptoms. Moving all machines away (A) is impractical as they are often essential. Explaining the condition (B) may not be effective during acute confusion. Extending visitation times (D) can be overwhelming for the client in the ICU.

2. A client who has been admitted to the psychiatric unit tells the nurse, 'My problems are so bad that no one can help me.' Which response is best for the nurse to make?

• A. How can I help?
• B. Things probably aren't as bad as they seem right now.
• C. Let's talk about what is right with your life.
• D. I hear how miserable you are, but things will get better soon.

Correct answer: A

Rationale: Offering self shows empathy and caring (A) and is the best choice provided. (B) dismisses the client's feelings and reality. (C) avoids addressing the client's concerns directly and may come across as invalidating. Although (D) starts with acknowledging the client's feelings, the second part about things getting better soon can be perceived as offering false reassurance, which is not recommended in therapeutic communication.

3. 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: C

Rationale: The correct response in this situation should focus on the connection between feelings of depression and drug abuse. Choice A is incorrect because addiction is treatable, not incurable. Choice B is incorrect as tolerance does not directly cause depression. Choice D is not the best response as the parent's concern is about the son's depression leading to suicidal thoughts, not just the withdrawal process.

4. A young adult male client, diagnosed with paranoid schizophrenia, believes that the world is trying to poison him. What intervention should the nurse include in this client's plan of care?

• A. Remind the client that his suspicions are not true
• B. Ask one nurse to spend time with the client daily
• C. Encourage the client to participate in group activities
• D. Assign the client to a room closest to the activity room

Correct answer: B

Rationale: The correct intervention for a client diagnosed with paranoid schizophrenia who believes in paranoid delusions is to ask one nurse to spend time with the client daily. Establishing a trusting relationship with a consistent caregiver can help reduce anxiety and foster a sense of security. Choice A is incorrect because directly challenging the client's beliefs may increase distress. Choice C might overwhelm the client with paranoia in a group setting. Choice D does not address the need for a trusting relationship with a specific caregiver.

5. A male client is admitted to the psychiatric inpatient unit with a bandaged flesh wound after attempting to shoot himself. He was divorced one year ago, lost his job four months ago, and suffered a breakup of his current relationship last week. What is the most likely source of this client's current feelings of depression?

• A. Feelings of frustration.
• B. A sense of loss.
• C. Poor self-esteem.
• D. A lack of intimate relationships.

Correct answer: B

Rationale: The client's recent life events, including divorce, job loss, and relationship breakup, all contribute to a significant sense of loss, which is likely the source of his current feelings of depression. While feelings of frustration and poor self-esteem could be present, the major life events the client has experienced are more closely associated with a sense of loss. A lack of intimate relationships is not the primary factor contributing to his depression in this scenario.

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