Nursing Elites

1. A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The nurse also determines that the client is homeless and slightly suspicious. This client’s treatment plan should include what priority problem?

• A. Self-care deficit.
• B. Disturbed sensory perception.
• C. Ineffective community coping.
• D. Acute confusion.

Correct answer: D

Rationale: The correct answer is 'D: Acute confusion.' In the given scenario, the client is disoriented, disorganized, and confused, indicating acute confusion. This is a priority issue to address for immediate safety and appropriate care. Option A, self-care deficit, is not the priority as the client's safety and mental status take precedence over self-care. Option B, disturbed sensory perception, is not applicable as the client's symptoms focus more on cognitive rather than sensory issues. Option C, ineffective community coping, is not the immediate concern as the client's cognitive state needs urgent attention to ensure her safety and well-being.

2. A client with depression and a history of a recent suicide attempt is being discharged from the hospital. Which statement by the client indicates a need for further follow-up?

• A. “I will take my medication as prescribed.”
• B. “I have a plan to attend weekly therapy sessions.”
• C. “I feel that I am completely recovered now.”
• D. “I will avoid people who make me feel worse.”

Correct answer: C

Rationale: The correct answer is C. When a client with depression and a history of a recent suicide attempt states, “I feel that I am completely recovered now,” it indicates a need for further follow-up. This statement suggests a potential lack of insight into the ongoing nature of depression and may lead to discontinuation of necessary treatment and support. Choices A, B, and D demonstrate positive and proactive attitudes towards managing depression and suicidal ideation, indicating a willingness to engage in treatment, therapy, and self-care practices.

3. A client with an eating disorder tells the RN, 'I’ve been eating only 400 calories per day and have been taking diuretics to lose weight.' What is the RN’s best response?

• A. “Your diet is very harmful and needs to be changed immediately.”
• B. “It’s important to monitor your calorie intake carefully.”
• C. “Have you noticed any physical effects from this low-calorie diet?”
• D. “The diuretics could be causing your body to lose essential nutrients.”

Correct answer: D

Rationale: The correct response is D. By addressing the potential harm of diuretics and the low-calorie diet, the nurse effectively addresses both aspects of the client's disordered eating behavior. Choice A is too direct and does not provide information on the specific issue of diuretics. Choice B focuses solely on monitoring calorie intake without addressing the use of diuretics. Choice C inquires about physical effects but does not address the overall risks associated with diuretics and low-calorie intake.

4. A client diagnosed with obsessive-compulsive disorder (OCD) engages in repetitive hand washing that lasts for several hours. Which strategy should the nurse use to manage this behavior?

• A. Encourage the client to continue the behavior to alleviate anxiety.
• B. Establish a routine schedule for hand washing.
• C. Gradually reduce the amount of time spent on the behavior.
• D. Ignore the behavior as much as possible.

Correct answer: C

Rationale: In managing obsessive-compulsive disorder (OCD), it's crucial to gradually reduce the compulsive behavior to help the client learn to manage anxiety in a structured manner. Encouraging the client to continue the behavior (Choice A) would reinforce the cycle of compulsions. While establishing a routine schedule (Choice B) may provide some structure, it doesn't address the core issue of excessive hand washing. Ignoring the behavior (Choice D) may lead to worsening symptoms and does not help the client in managing their OCD effectively.

5. 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.

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