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. During an annual physical at 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 a 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 there are many situations that make you feel angry.”

Correct answer: B

Rationale: The correct response is to encourage the client to manage their anger and avoid impulsive actions, as stated in choice B. This approach helps the individual recognize the potential consequences of acting on their anger impulsively. Choice A is not the best response because it focuses on the contagious nature of anger rather than addressing the individual's behavior. Choice C is incorrect as it only highlights the potential dangers of expressing anger to a stranger without providing guidance on managing the underlying issue. Choice D acknowledges the client's feelings but does not offer practical advice on how to address the anger and potential impulsive actions.

3. A female client engages in repeated checks of door and window locks, a behavior that prevents her from arriving on time and interferes with her ability to function effectively. What action should the nurse take?

• A. Ask the client why she checks the locks.
• B. Discuss checking the time frequently.
• C. Determine the type and size of the locks.
• D. Plan a list of activities to be carried out daily.

Correct answer: D

Rationale: Planning a list of daily activities can help the client manage her time better and reduce the impact of her compulsive behaviors. This structured approach can assist the client in organizing her day, potentially reducing the need for excessive lock checking. Option A is incorrect because simply asking why the client checks the locks may not address the underlying issue effectively. Option B is not relevant to the compulsive behavior of checking locks and does not offer a practical solution. Option C does not directly address the client's compulsive behavior but focuses on the physical attributes of the locks, which is not the primary concern in this scenario.

4. A client with a recent diagnosis of bipolar disorder is attending a support group for the first time. Which statement made by the client indicates a need for further education about the disorder?

• A. “I will make sure to take my medications every day.”
• B. “I will avoid high-stress situations whenever possible.”
• C. “I know I can stop my medications when I am feeling better.”
• D. “I should monitor my mood changes closely.”

Correct answer: C

Rationale: The correct answer is C because it shows a misconception about bipolar disorder treatment. Stopping medications when feeling better can lead to a relapse or worsening of symptoms. Choice A is correct because medication adherence is crucial in managing bipolar disorder. Choice B is also a good strategy as stress management is important in symptom control. Choice D is a proactive approach to self-awareness and can help in recognizing early signs of mood changes.

5. While sitting in the day room of the mental health unit, a male adolescent avoids eye contact, looks at the floor, and talks softly when interacting verbally with the RN. The two trade places, and the RN demonstrates the client's behaviors. What is the main goal of this therapeutic technique?

• A. Initiate a non-threatening conversation with the client.
• B. Dialog about the ineffectiveness of his interactions.
• C. Allow the client to identify the way he interacts.
• D. Discuss the client's feelings when he responds.

Correct answer: C

Rationale: The main goal of the therapeutic technique described is to allow the client to identify the way he interacts. This technique helps promote self-awareness in the client by mirroring his behavior back to him, which can lead to insights about his own communication style. Option A is incorrect as the goal is not just to initiate conversation but to facilitate self-reflection. Option B is incorrect because the focus is not on discussing the ineffectiveness of the interactions but on self-awareness. Option D is incorrect as the primary aim is not to discuss the client's feelings but to help him recognize his interaction patterns.

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