Nursing Elites

1. A client with schizophrenia is experiencing delusions. What is the most appropriate nursing intervention?

• A. Encourage the client to explore the delusions in depth.
• B. Tell the client that the delusions are not real.
• C. Explore the underlying meaning of the delusions.
• D. Distract the client from the delusions and focus on reality.

Correct answer: D

Rationale: The most appropriate nursing intervention for a client with schizophrenia experiencing delusions is to distract the client from the delusions and focus on reality. Encouraging the client to explore the delusions in depth (Choice A) may worsen the delusions. Telling the client that the delusions are not real (Choice B) can lead to confrontation and disbelief. Exploring the underlying meaning of the delusions (Choice C) may not be effective during acute episodes of delusions; hence, distracting the client and refocusing on reality is the most suitable intervention.

2. The community health nurse talks to a male client who has bipolar disorder. The client explains that he sleeps 4 to 5 hours a night and is working with his partner to start two new businesses and build an empire. The client stopped taking his medications several days ago. What nursing problem has the highest priority?

• A. Excessive work activity.
• B. Decreased need for sleep.
• C. Medication management.
• D. Inflated self-esteem.

Correct answer: D

Rationale: The priority is to manage the client's medication adherence to prevent escalation of manic behavior. Inflated self-esteem is the highest priority as it indicates the client's potential for harmful behaviors due to lack of medication compliance. While excessive work activity and decreased need for sleep are characteristics of mania, they are not as immediately concerning as the risk of harm related to inflated self-esteem.

3. The client with schizophrenia believes the news commentator is her lover and speaks to her. What is the best response for the nurse to make?

• A. What do you believe the news commentator said to you?
• B. Let's switch to a different news channel.
• C. Is the news commentator planning to harm you or others?
• D. The news commentator is not communicating with you.

Correct answer: A

Rationale: The correct response is to ask the client what she believes the news commentator said, as it helps the nurse assess the client's perception and delve into her delusions without being confrontational. Choice B is not helpful in addressing the client's delusions. Choice C jumps to conclusions about potential harm without assessing the client's beliefs. Choice D is dismissive and does not address the client's reality.

4. A LVN/LPN is caring for a client with anorexia nervosa. The nurse is monitoring the behavior of the client and understands that a client with anorexia nervosa manages anxiety by:

• A. Engaging in immoral acts
• B. Always reinforcing self-approval
• C. Observing rigid rules and regulations
• D. Having the need always to make the right decision

Correct answer: C

Rationale: Clients with anorexia nervosa often manage anxiety by adhering strictly to rules and regulations as a way to maintain control. Choice A is incorrect because engaging in immoral acts is not a common coping mechanism for clients with anorexia nervosa. Choice B is incorrect as self-approval is not typically the primary way clients with anorexia nervosa manage anxiety. Choice D is incorrect because while clients with anorexia nervosa may have a need to make the right decision, it is not the primary way they manage their anxiety.

5. During an annual physical by the occupational nurse working in a corporate clinic, a male employee tells the nurse that his high-stress job is causing trouble in his personal life. He further explains that he often gets so angry while driving to and from work that he has considered 'getting even' with other drivers. How should the nurse respond?

• A. Anger is contagious and could result in major confrontation.
• B. Try not to let your anger cause you to act impulsively.
• C. Expressing your anger to a stranger could result in an unsafe situation.
• D. It sounds as if you feel angry for no reason

Correct answer: C

Rationale: The correct responses are C and D. The nurse should acknowledge the employee's feelings of anger and suggest that expressing anger to strangers, like other drivers, could lead to unsafe situations. This response aims to prevent potential confrontations or harm. Choice A is incorrect as it doesn't address the specific situation of expressing anger while driving. Choice B is also incorrect as it is vague and doesn't provide practical advice to manage the anger effectively.

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