Nursing Elites

1. A client tells the RN that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. What is the priority nursing problem for admission to the psychiatric unit?

• A. Ineffective sexual patterns.
• B. Impaired environmental interpretation.
• C. Disturbed sensory perception.
• D. Compromised family coping.

Correct answer: C

Rationale: The priority nursing problem for admission to the psychiatric unit is 'Disturbed sensory perception.' This choice is correct because the client's delusional beliefs about having an IQ of 400+, being a genius and an inventor, being married to a movie star, and suspecting his brother of wanting a sexual relationship with her indicate a significant disturbance in sensory perception. The client's perceptions are not based in reality, indicating a need for immediate intervention to address these distorted beliefs. Choices A, B, and D are incorrect: 'Ineffective sexual patterns' is not the priority as the client's delusions go beyond just sexual relationships, 'Impaired environmental interpretation' does not capture the primary issue of distorted perceptions, and 'Compromised family coping' is not the priority concern in this scenario compared to the severe sensory perception disturbances displayed by the client.

2. The RN is leading a group on the inpatient psychiatric unit. Which approach should the RN use during the working phase of group development?

• A. Establishing a rapport with group members.
• B. Clarifying the nurse’s role and clients’ responsibilities.
• C. Discussing ways to use new coping skills learned.
• D. Helping clients identify areas of problems in their lives.

Correct answer: C

Rationale: During the working phase of group development, the focus should be on discussing and applying new coping skills to promote progress. This helps group members to practice and implement the skills they have learned, leading to positive outcomes. Choices A, B, and D are not ideal during the working phase. While establishing rapport is important, it is more relevant during the initial orientation phase. Clarifying roles and responsibilities is important at the beginning of group formation, and helping clients identify areas of problem in their lives is often part of the exploration phase, not the working phase.

3. A female client, who is wearing dirty clothes and has a foul body odor, comes to the clinic reporting feeling scared because she is being stalked. What action is most important for the nurse to take?

• A. Assure the client that she will be seen by a healthcare provider today.
• B. Recommend that the client speaks with a social worker.
• C. Ask the client if she feels comfortable sharing why she is being stalked.
• D. Offer the client a safe place to relax before interviewing her.

Correct answer: D

Rationale: The most important action for the nurse to take in this scenario is to offer the client a safe place to relax before interviewing her. The client's disheveled appearance and foul body odor suggest she may be in distress or facing challenging circumstances. By providing her with a safe and comfortable environment to relax, the nurse can help alleviate some of her distress and establish trust. This approach is crucial as the client is already feeling scared due to being stalked, indicating underlying mental health concerns. Assuring the client that she will be seen by a healthcare provider today (choice A) may not address her immediate need for safety and comfort. Recommending she speaks with a social worker (choice B) may be beneficial later but does not address the immediate need for a safe space. Asking the client if she feels comfortable sharing why she is being stalked (choice C) is not appropriate as the priority is ensuring her safety and comfort first.

4. A client with schizophrenia is exhibiting visual and auditory hallucinations. What should be the RN’s initial intervention?

• A. Instruct the client to ignore the hallucinations.
• B. Encourage the client to describe the hallucinations in detail.
• C. Assess the client’s perception of the hallucinations.
• D. Provide reassurance that the hallucinations are not real.

Correct answer: C

Rationale: The correct initial intervention for a client with schizophrenia exhibiting visual and auditory hallucinations is to assess the client’s perception of the hallucinations. This step is crucial as it helps the RN determine the severity of the hallucinations and the best course of action for management and intervention. Instructing the client to ignore the hallucinations (Choice A) may not be effective as the hallucinations may be distressing and overwhelming. Encouraging the client to describe the hallucinations in detail (Choice B) may potentially worsen the symptoms or trigger further distress. Providing reassurance that the hallucinations are not real (Choice D) may not be appropriate as the client may genuinely believe in their reality, and this reassurance may not address the underlying issues causing the hallucinations.

5. The nurse is completing the admission assessment of an underweight adolescent admitted to the psychiatric unit with a diagnosis of depression. Which finding requires notification to the healthcare provider?

• A. Body mass index of 21
• B. Potassium level of 2.9 mEq/dL
• C. WBC count of 10,000/mm3
• D. Blood pressure of 110/70 mmHg

Correct answer: B

Rationale: The correct answer is B. A potassium level of 2.9 mEq/dL is critically low and requires immediate notification to the healthcare provider as it indicates a potential electrolyte imbalance, which can lead to serious cardiac arrhythmias and other complications. Choices A, C, and D are within normal ranges or not indicative of immediate life-threatening issues. A body mass index of 21 may be considered normal for some individuals, a WBC count of 10,000/mm3 is slightly elevated but not an urgent concern, and a blood pressure of 110/70 mmHg is within normal limits for an adolescent.

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