Nursing Elites

1. A client is admitted to the mental health unit and reports taking extra antianxiety medication because, “I’m so stressed out. I just wanted to go sleep.” The nurse should plan one-on-one observation of the client based on which statement?

• A. What should I do? Nothing seems to help.
• B. I have been so tired lately and needed to sleep.
• C. I really think that I don’t need to be here.
• D. I don’t want to talk. Nothing matters anymore.

Correct answer: D

Rationale: The client's statement of not wanting to talk and feeling that nothing matters anymore is indicative of severe depression or a risk for self-harm. This warrants immediate attention and one-on-one observation to ensure the client's safety. Choices A, B, and C do not express the same level of concerning behavior and do not imply an immediate risk to the client's well-being.

2. James is a 42-year-old patient with schizophrenia. He approaches you as you arrive for day shift and anxiously reports, 'Last night, demons came to my room and tried to rape me.' Which response would be most therapeutic?

• A. There are no such things as demons. What you saw were hallucinations.
• B. It is not possible for anyone to enter your room at night. You are safe here.
• C. You seem very upset. Please tell me more about what you experienced last night.
• D. That must have been very frightening, but we will check on you at night and you will be safe.

Correct answer: C

Rationale: Choice C is the most therapeutic response as it acknowledges the patient's feelings and encourages further exploration of their experience. By expressing empathy and inviting James to share more about what he experienced, it helps build trust and rapport. Choices A and B dismiss the patient's experience and can make them feel invalidated, which is not helpful in establishing a therapeutic relationship. Choice D acknowledges the fear but does not actively engage the patient in discussing their feelings and experiences, missing an opportunity for therapeutic communication.

3. A male adolescent was admitted to the unit two days ago for depression. When the mental health nurse tries to interview the client to establish rapport, he becomes very irritated and sarcastic. Which action is best for the nurse to take?

• A. Offer to play a game of cards with the client.
• B. Report the behavior to the next shift.
• C. Document the behavior in the chart.
• D. Plan to talk with the client the next day.

Correct answer: A

Rationale: Offering to play a game of cards with the adolescent is the best action for the nurse to take in this situation. Engaging in an activity like playing a game can help establish rapport with the adolescent as it provides a more relaxed and non-threatening environment for communication. This approach can help the adolescent feel more comfortable and open up, as adolescents often find it easier to communicate when involved in an activity. Reporting the behavior to the next shift, documenting the behavior, or planning to talk with the client the next day do not directly address the immediate need to establish rapport and improve communication with the adolescent.

4. The client is being educated by the healthcare provider about starting a prescribed abstinence therapy with disulfiram (Antabuse). What information should the client understand?

• A. Maintain complete abstinence from alcohol consumption.
• B. Stay alcohol-free for at least 12 hours before the first dose.
• C. Participate in monthly therapy sessions.
• D. Disclose to others that he is receiving disulfiram therapy.

Correct answer: B

Rationale: The correct answer is B. Before starting disulfiram therapy (Antabuse), the client must comprehend the need to remain alcohol-free for a minimum of 12 hours. This is crucial to prevent the unpleasant and potentially dangerous reactions that can occur with concurrent alcohol consumption while on disulfiram. Choice A is incorrect because it mentions heroin or cocaine use, which is not the primary focus when initiating disulfiram therapy. Choice C is incorrect as it suggests therapy sessions, which are not specifically required before starting disulfiram. Choice D is incorrect as there is no need to disclose disulfiram therapy to others, but rather to adhere to the abstinence requirement.

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 history of divorce, job loss, and breakup of a current relationship indicates a series of significant losses. These losses are likely the primary source of his feelings of depression, leading to a sense of loss. While feelings of frustration (choice A) and poor self-esteem (choice C) could be contributing factors, the immediate trigger for his current emotional state appears to be the series of losses. A lack of intimate relationships (choice D) may be a consequence of the client's depressive symptoms rather than the root cause in this scenario.

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