Nursing Elites

1. A 65-year-old female client complains to the nurse that recently she has been hearing voices. What question should the nurse ask this client first?

• A. Do you have problems with hallucinations?
• B. Are you ever alone when you hear the voices?
• C. Has anyone in your family had hearing problems?
• D. Do you see things that others cannot see?

Correct answer: B

Rationale: The nurse should first ask if the client is ever alone when she hears the voices. This question helps differentiate between potential auditory hallucinations and other causes like hearing loss. Choice A is not the best first question as it assumes the client is experiencing hallucinations without exploring other possibilities. Choice C is irrelevant to the immediate concern of hearing voices. Choice D pertains to visual hallucinations which are not described in the client's complaint of hearing voices.

2. Select the nursing interventions for a hospitalized client with mania who is exhibiting manipulative behavior. Select one intervention that does not apply.

• A. Communicate expected behaviors to the client
• B. Ensure that the client knows that he or she is not in charge of the nursing unit
• C. Assist the client in identifying ways of setting limits on personal behaviors
• D. Follow through about the consequences of behavior in a non-punitive manner

Correct answer: B

Rationale: The correct answer is B. Ensuring that the client knows they are not in charge of the nursing unit is not a helpful nursing intervention for managing manipulative behavior in a client with mania. Communicating expected behaviors, assisting with limit-setting, and following through on consequences in a non-punitive manner are more appropriate interventions to address manipulative behavior.

3. A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. What action should the nurse implement?

• A. Attempt to ask the client simple questions.
• B. Postpone the client interview until the next day.
• C. Ask another nurse to talk with the client.
• D. Document the client's paranoid behavior.

Correct answer: A

Rationale: When a client is guarded, suspicious, and resistant to talking, it is important for the nurse to attempt to ask the client simple questions. Simple questions can help build rapport, establish trust, and create a non-threatening environment. This approach may ease the client into more detailed discussions while reducing feelings of suspicion. Postponing the interview may increase the client's anxiety and distrust, while asking another nurse to talk with the client may disrupt continuity of care and the establishment of a therapeutic relationship. Documenting the client's behavior is important for the client's medical record, but it should not be the first action taken in this situation.

4. A client with schizophrenia is being treated with clozapine (Clozaril). What laboratory test is most important for the nurse to monitor?

• A. Liver function tests
• B. Kidney function tests
• C. White blood cell count
• D. Blood glucose levels

Correct answer: C

Rationale: The correct answer is C: White blood cell count. Clozapine can lead to agranulocytosis, a severe drop in white blood cells, which can be life-threatening. Monitoring the white blood cell count is crucial to detect this condition early. Choices A, B, and D are incorrect because while liver and kidney function tests are important in monitoring other aspects of health, the most critical concern with clozapine therapy is the risk of agranulocytosis, making monitoring white blood cell count the priority.

5. On admission to a residential care facility, an elderly female client tells the nurse that she enjoys cooking, quilting, and watching television. Twenty-four hours after admission, the nurse notes that the client is withdrawn and isolated. It is best for the nurse to encourage this client to become involved in which activity?

• A. Clean the unit kitchen cabinets.
• B. Participate in a group quilting project.
• C. Watch television in the activity room.
• D. Bake a cake for a resident's birthday.

Correct answer: B

Rationale: Peer interaction in a group activity (B) such as participating in a group quilting project will help to prevent social isolation and withdrawal. This will provide the elderly client with an opportunity to engage with others, share experiences, and feel a sense of belonging. Choices (A, C, and D) are activities that can be accomplished alone, without peer interaction, which may not effectively address the client's feelings of withdrawal and isolation.

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