Nursing Elites

1. A client is responding to auditory hallucinations and shakes a fist at a nurse and says, 'Back off, witch!' The nurse follows the client into the day room. What action should the nurse implement?

• A. Sit down in a chair near the client.
• B. Position self within an arm's length of the client.
• C. Ensure that there is physical space between the nurse and client.
• D. Move to a position that allows the client to be closest to the room's door.

Correct answer: C

Rationale: In situations where a client is responding to auditory hallucinations and displaying aggressive behavior, it is crucial for the nurse to ensure physical space between themselves and the client. This action can help de-escalate the situation and prevent any potential harm to both the nurse and the client. Sitting down near the client (Choice A) may escalate the situation by invading the client's personal space. Positioning oneself within an arm's length of the client (Choice B) may increase the risk of physical confrontation. Moving closer to the room's door (Choice D) may not be appropriate as it can block the client's exit route and escalate the situation further. Therefore, ensuring physical space between the nurse and the client (Choice C) is the most appropriate action to promote safety and prevent escalation.

2. A client with schizophrenia is experiencing auditory hallucinations. What is the most appropriate nursing intervention?

• A. Encourage the client to ignore the voices.
• B. Ask the client what the voices are saying.
• C. Distract the client with a new activity.
• D. Tell the client that the voices are not real.

Correct answer: B

Rationale: Asking the client what the voices are saying is the most appropriate intervention as it helps the nurse assess the content of the hallucinations and the potential risk they may pose. Encouraging the client to ignore the voices (Choice A) may not address the underlying issue or provide valuable information for the nurse. Distracting the client with a new activity (Choice C) may temporarily divert attention but does not address the hallucinations. Telling the client that the voices are not real (Choice D) may invalidate the client's experience and can lead to distrust in the therapeutic relationship.

3. A male client with delirium becomes disoriented and confused in his room at night. The best initial nursing intervention is to:

• A. Move the client next to the nurse's station
• B. Use an indirect light source and turn off the television
• C. Keep the television and a soft light on during the night
• D. Play soft music during the night, and maintain a well-lit room

Correct answer: B

Rationale: The best initial nursing intervention for a male client with delirium who becomes disoriented and confused in his room at night is to use an indirect light source and turn off the television. This approach helps to reduce stimulation and confusion, aiding in the client's orientation and comfort. Moving the client next to the nurse's station (Choice A) may not address the root cause of disorientation and could disrupt the client's routine. Keeping the television and a soft light on (Choice C) may further contribute to the client's confusion. Playing soft music and maintaining a well-lit room (Choice D) may not be as effective in reducing stimulation and promoting orientation as using an indirect light source and turning off the television.

4. A male client who is participating in an anger management assignment asks if he can make a leather belt in occupational therapy. The client begins pounding the leather vigorously with a mallet to imprint designs on the belt. What defense mechanism is the client using?

• A. Sublimation
• B. Suppression
• C. Regression
• D. Compensation

Correct answer: A

Rationale: The correct answer is A, Sublimation. Sublimation is a defense mechanism where unacceptable impulses are redirected into socially acceptable activities, such as art or work. In this scenario, the client is channeling his anger into a creative and constructive task like making a leather belt. Choice B, Suppression, involves consciously pushing down or hiding feelings rather than expressing them through alternate means. Choice C, Regression, refers to reverting to earlier, immature behaviors when faced with stress. Choice D, Compensation, involves making up for a perceived weakness in one area by excelling in another, which is not demonstrated in the scenario provided.

5. Based on non-compliance with the medication regimen, an adult client with a medical diagnosis of substance abuse and schizophrenia was recently switched from oral fluphenazine HCl (Prolixin) to IM fluphenazine decanoate (Prolixin Decanoate). What is most important to teach the client and family about this change in medication regimen?

• A. Signs and symptoms of extrapyramidal effects (EPS).
• B. Information about substance abuse and schizophrenia.
• C. The effects of alcohol and drug interaction.
• D. The availability of support groups for those with dual diagnoses.

Correct answer: C

Rationale: Teaching about the effects of alcohol and drug interaction is crucial to prevent adverse reactions, especially with the long-acting injectable form of fluphenazine. Understanding how alcohol and drugs can interact with the medication will help the client and family to ensure medication effectiveness and avoid potential harmful effects. Choices A, B, and D are not the most important to teach in this scenario. While knowing the signs and symptoms of extrapyramidal effects (EPS) is important, understanding the effects of alcohol and drug interaction is more critical in this specific situation. Information about substance abuse and schizophrenia, as well as the availability of support groups, are essential aspects of care but are not the primary focus when switching to a long-acting injectable medication due to non-compliance.

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