Nursing Elites

1. A client tells a nurse, 'Don’t tell anyone, but I hid a sharp knife under my mattress to protect myself from my threatening roommate.' Which of the following actions should the nurse take?

• A. Keep the client’s communication confidential, but talk to the client daily using therapeutic communication to convince them to admit to hiding the knife
• B. Keep the client’s communication confidential, but watch the client and their roommate closely
• C. Tell the client that this must be reported to the health care team because it concerns the health and safety of the client and others
• D. Report the incident to the health care team but do not inform the client of the intention to do so

Correct answer: C

Rationale: In this scenario, the nurse must prioritize the safety of the client and others. The client's disclosure of hiding a sharp knife under the mattress poses a significant risk. It is crucial for the nurse to inform the health care team about this situation to ensure immediate intervention and prevent any harm. Confidentiality is important in nursing care, but in cases where there is a clear threat to safety, the duty to protect overrides the duty of confidentiality. Reporting the incident to the health care team is essential to address the safety concerns and provide appropriate support and intervention for the client. Choices A and B are incorrect because while confidentiality is important, the immediate safety concern outweighs keeping the client's communication confidential or simply monitoring the situation. Choice D is incorrect as it does not involve informing the client, which can impact the therapeutic relationship and trust between the nurse and the client.

2. When caring for a patient with dissociative identity disorder, which nursing intervention is a priority?

• A. Providing detailed education about the condition
• B. Monitoring for signs of self-harm or suicidal ideation
• C. Encouraging the patient to recall traumatic events
• D. Helping the patient develop a strong sense of identity

Correct answer: B

Rationale: When caring for a patient with dissociative identity disorder, the priority nursing intervention is to monitor for signs of self-harm or suicidal ideation. Ensuring patient safety is crucial, as individuals with this disorder may be at increased risk of self-harm or suicidal behaviors. Providing education about the condition is beneficial but ensuring immediate safety takes precedence. Encouraging the patient to recall traumatic events can be detrimental and should be done cautiously under professional guidance. While helping the patient develop a strong sense of identity is important in the long term, it is not the immediate priority when safety is a concern.

3. A nurse is planning care for several clients attending community-based mental health programs. Which of the following clients should the nurse visit first?

• A. A client who received a burn on the arm while using a hot iron at home
• B. A client who requests a change of antipsychotic medication due to new adverse effects
• C. A client who reports hearing a voice saying that life is not worth living anymore
• D. A client who tells the nurse about experiencing manifestations of severe anxiety before and during a job interview

Correct answer: C

Rationale: The nurse should visit the client who reports hearing a voice saying that life is not worth living anymore first. This statement indicates potential suicidal ideation, which requires immediate intervention to ensure the client's safety. Choices A, B, and D do not present an immediate threat to the client's life. While burns, adverse effects of medication, and severe anxiety are important concerns, they do not pose an immediate risk of self-harm or suicide.

4. During a panic attack, what is the most appropriate nursing intervention?

• A. Encourage the patient to talk about their feelings.
• B. Provide a quiet, non-stimulating environment.
• C. Administer prescribed medication immediately.
• D. Teach the patient relaxation techniques.

Correct answer: B

Rationale: During a panic attack, a quiet, non-stimulating environment is the most appropriate nursing intervention. This helps reduce stimuli that may exacerbate the panic attack and allows the individual to focus on calming down. Encouraging the patient to talk about their feelings may not be effective during an acute panic attack as the focus should be on reducing stimuli. Administering medication should follow healthcare provider's orders and may not be the initial intervention. Teaching relaxation techniques is beneficial in managing anxiety but may not be the priority during the acute phase of a panic attack where reducing stimuli is crucial.

5. Luc’s family comes home one evening to find him extremely agitated, and they suspect he is in a full manic episode. The family calls emergency medical services. While one medic is talking with Luc and his family, the other medic is counting something on his desk. What is the medic most likely counting?

• A. Hypodermic needles
• B. Fast food wrappers
• C. Empty soda cans
• D. Energy drink containers

Correct answer: D

Rationale: The medic is most likely counting energy drink containers. Energy drink containers could indicate high caffeine intake, which can exacerbate manic episodes by increasing agitation and exacerbating symptoms in individuals with mood disorders.

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