Nursing Elites

1. A client who has agoraphobia (a fear of crowds) is starting desensitization therapy with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care?

• A. Encourage the substitution of positive thoughts for negative ones.
• B. Establish trust by providing a calm, safe environment.
• C. Gradually expose the client to larger crowds.
• D. Encourage deep breathing when anxiety escalates in a crowd.

Correct answer: B

Rationale: Establishing trust by providing a calm and safe environment is crucial for the success of desensitization therapy in clients with agoraphobia. This approach helps the client feel safe and secure, allowing them to gradually confront their fear of crowds. Encouraging positive thoughts (choice A) is beneficial but not as immediately critical as creating a safe space. Progressively exposing the client to larger crowds (choice C) should occur after trust is established and in a controlled manner. Encouraging deep breathing (choice D) is helpful, but creating a safe environment takes precedence to build a foundation for successful desensitization.

2. The RN on the evening shift receives a report that a client is scheduled for electroconvulsive treatment (ECT) in the morning. Which intervention should the RN implement the evening before the scheduled ECT?

• A. Hold all bedtime medications.
• B. Keep the client NPO after midnight.
• C. Implement elopement precautions.
• D. Give the client an enema at bedtime.

Correct answer: B

Rationale: Keeping the client NPO after midnight is the appropriate intervention before ECT to prevent complications during the procedure. Withholding food and fluids reduces the risk of aspiration and helps ensure the safety of the client. Option A (Hold all bedtime medications) is incorrect because medications may need to be given as prescribed unless specified otherwise by the healthcare provider. Option C (Implement elopement precautions) is unrelated to preparing a client for ECT and focuses on preventing a client from leaving the treatment area. Option D (Give the client an enema at bedtime) is unnecessary and not a standard pre-ECT preparation, making it an incorrect choice.

3. The occupational health nurse is working with a female employee who was just notified that her child was involved in a motor vehicle accident (MVA) and taken to the hospital. The employee states, “I can’t believe this. What should I do?” Which response is best for the nurse to provide in this crisis?

• A. Tell me what you think should be done.
• B. How serious was the collision?
• C. What do you think you should do?
• D. Call for transportation to the hospital.

Correct answer: D

Rationale: In a crisis situation where the female employee's child is involved in a motor vehicle accident (MVA) and taken to the hospital, the most appropriate response for the nurse is to provide immediate practical assistance. Calling for transportation to the hospital ensures that the employee can quickly reach her child in need of urgent medical attention. The other options (A, B, and C) do not address the immediate need for assistance and may not provide the necessary support required in such a critical situation.

4. What assessment question will provide healthcare providers with information regarding the effects of a woman's circadian rhythms on her quality of life?

• A. How much sleep do you usually get each night?
• B. Does your heart ever seem to skip a beat?
• C. When was the last time you had a fever?
• D. Do you have problems urinating?

Correct answer: A

Rationale: Asking about the amount of sleep a woman gets each night is crucial in understanding her circadian rhythms and how they may affect her quality of life. Circadian rhythms are the body's internal clock that regulates the sleep-wake cycle. Monitoring sleep patterns can provide insights into how well these rhythms are functioning and impacting daily life. Choices B, C, and D are unrelated to circadian rhythms and do not directly assess the effects of these rhythms on quality of life.

5. A male client with schizophrenia tells the RN that he is being watched and that the television is speaking directly to him. Which response by the RN is appropriate?

• A. “The television cannot speak to you.”
• B. “That sounds very frightening for you.”
• C. “You should ignore the television.”
• D. “Why do you think the television is talking to you?”

Correct answer: B

Rationale: Option B is the correct response because it acknowledges the client's feelings and demonstrates empathy. By stating that the situation sounds frightening, the RN validates the client's experience without denying or reinforcing the delusion. This approach helps build rapport and trust with the client, which is essential in therapeutic communication. Options A and C are dismissive and may invalidate the client's experience, potentially worsening the trust relationship. Option D is confrontational and may make the client defensive, hindering effective communication and rapport-building.

Similar Questions