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. While interviewing a client, the nurse takes notes to assist with accurate documentation later. Which statement is most accurate regarding note-taking during an interview?

• A. The client’s comfort level is increased when the nurse maintains eye contact while taking notes.
• B. The interview process is enhanced with note-taking, allowing the client to speak at a normal pace.
• C. Note-taking during an interview is not a legal obligation of the examining nurse.
• D. The nurse’s ability to directly observe the client’s nonverbal communication is limited with note-taking.

Correct answer: D

Rationale: During an interview, note-taking can hinder the nurse’s ability to directly observe the client's nonverbal cues such as body language, facial expressions, and tone of voice. These nonverbal cues are crucial for understanding the client's emotions, feelings, and overall communication. Therefore, it is essential for the nurse to strike a balance between note-taking for documentation purposes and actively observing the client's nonverbal communication to ensure a comprehensive assessment. Choices A, B, and C are incorrect because maintaining eye contact, enhancing the interview process with note-taking, and legal obligations of note-taking during an interview do not directly address the issue of limited observation of nonverbal communication while taking notes.

3. A client who is admitted to the mental health unit reports shortness of breath and dizziness. The client tells the nurse, “I feel like I’m going to die.” Which nursing problem should the nurse include in this client’s plan of care?

• A. Mood disturbance
• B. Moderate anxiety
• C. Altered thoughts
• D. Social isolation

Correct answer: B

Rationale: The correct answer is B: Moderate anxiety. When a client presents with symptoms such as shortness of breath, dizziness, and a fear of dying, it indicates moderate anxiety. Anxiety can manifest physically with symptoms like these. Mood disturbance (choice A) refers to a change in mood, while altered thoughts (choice C) relate to cognitive changes. Social isolation (choice D) involves a lack of social interaction, which is not the primary concern in this scenario where the client is experiencing acute anxiety symptoms.

4. A male veteran who recently returned from a war zone has post-traumatic stress disorder (PTSD) and is admitted to the psychiatric ward due to admitted suicidal ideation. On admission, the client’s family informed the healthcare provider that therapy sessions did not seem to be helping. Select only one intervention that has the highest priority.

• A. Administer paroxetine 40 mg as prescribed.
• B. Develop a list of therapy programs.
• C. Remove all shaving equipment.
• D. Determine if the client has a suicide plan.

Correct answer: C

Rationale: The highest priority intervention in this scenario is to ensure the safety of the client who is admitted due to suicidal ideation. Removing all shaving equipment is crucial to prevent self-harm or suicide attempts using sharp objects. Administering medication or developing a list of therapy programs can be important but ensuring immediate safety takes precedence. Determining if the client has a suicide plan is also essential but not as urgent as removing potential means for self-harm.

5. A male client approaches the nurse with an angry expression on his face and raises his voice, saying, “My roommate is the most selfish, self-centered, angry person I have ever met. If he loses his temper one more time with me, I am going to punch him out!” The nurse recognizes that the client is using which defense mechanism?

• A. Denial
• B. Projection
• C. Rationalization
• D. Splitting

Correct answer: B

Rationale: The correct answer is B: Projection. In this scenario, the client is projecting his own feelings of anger onto his roommate by attributing his anger to the roommate. Projection involves shifting one's feelings, thoughts, or impulses onto another person. Denial (choice A) is the refusal to accept reality, Rationalization (choice C) involves justifying behaviors with logical reasons, and Splitting (choice D) is the inability to integrate positive and negative qualities of oneself or others.

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