Nursing Elites

1. A female client requests that her husband be allowed to stay in the room during the admission assessment. While interviewing the client, the nurse notes a discrepancy between the client’s verbal and nonverbal communication. What action should the nurse take?

• A. Pay close attention and document the nonverbal messages.
• B. Ask the client’s husband to interpret the discrepancy.
• C. Ignore the nonverbal behavior and focus on the client’s verbal messages.
• D. Integrate the verbal and nonverbal messages and interpret them as one.

Correct answer: A

Rationale: When a nurse observes a discrepancy between a client's verbal and nonverbal communication, it is essential to pay close attention and document the nonverbal messages. Nonverbal cues, such as body language and facial expressions, can provide valuable insights into the client's emotional state, feelings, and concerns that may not be expressed verbally. By documenting these nonverbal messages, the nurse can gain a more comprehensive understanding of the client's communication and address any potential underlying issues. Asking the client's husband to interpret the discrepancy (Choice B) may not always provide an accurate understanding of the client's nonverbal cues. Ignoring the nonverbal behavior (Choice C) could lead to missing important cues affecting the client's care. Integrating verbal and nonverbal messages (Choice D) is important, but initially focusing on documenting and understanding the nonverbal cues can enhance the nurse's assessment and communication with the client.

2. A client is admitted for bipolar disorder and alcohol withdrawal, depressive phase. Based on which assessment finding will the RN withhold the clonidine (Catapres) prescription?

• A. Blood pressure readings of 90/62 mmHg to 92/58 mmHg.
• B. Pulse rate of 68-78 BPM.
• C. Temperature of 99.5-99.7°F.
• D. Respiration rate of 24 breaths per minute.

Correct answer: A

Rationale: In this scenario, the correct answer is A. Clonidine, such as Catapres, is a medication that can lower blood pressure. Therefore, if a client has low blood pressure readings, like 90/62 mmHg to 92/58 mmHg, the registered nurse should withhold the clonidine prescription to prevent further lowering of blood pressure which could lead to adverse effects. Choices B, C, and D are incorrect because they are within normal ranges and do not present a contraindication for the administration of clonidine in this context.

3. To provide effective care for a patient diagnosed with schizophrenia, what associated condition should the nurse frequently assess for? Select all that apply.

• A. Alcohol use disorder
• B. Major depressive disorder
• C. Stomach cancer
• D. Polydipsia

Correct answer: A

Rationale: Alcohol use disorder is commonly associated with schizophrenia, leading to a dual diagnosis. Assessing for alcohol use disorder is crucial in managing the patient's overall well-being and treatment plan. Major depressive disorder can co-occur with schizophrenia but is not the most commonly associated condition. Stomach cancer is not typically associated with schizophrenia. Polydipsia, excessive thirst, can be a symptom in some individuals with schizophrenia due to medication side effects, but it is not an associated condition that requires frequent assessment compared to alcohol use disorder.

4. During admission to the psychiatric unit, a female client is extremely anxious and states that she is worried about the sun coming up the next day. What intervention is most important for the RN to implement during the admission process?

• A. Assist the client in developing alternative coping skills.
• B. Remain calm and use a matter-of-fact approach.
• C. Ask the client why she is so anxious.
• D. Administer a PRN sedative to help relieve her anxiety.

Correct answer: B

Rationale: During admission to a psychiatric unit, it is crucial for the registered nurse to remain calm and use a matter-of-fact approach when addressing a client who is extremely anxious. By staying composed and adopting a matter-of-fact demeanor, the nurse can help establish trust and promote a sense of calm in the client. This approach can also convey a sense of reassurance and stability, which can be beneficial in managing the client's anxiety. Assisting the client in developing alternative coping skills (Choice A) may be important in the long term but is not the most immediate priority during the admission process. Asking the client why she is anxious (Choice C) may not be helpful at this moment as the client may not be able to articulate the specific reasons due to her heightened anxiety. Administering a PRN sedative (Choice D) should not be the initial intervention as it does not address the underlying cause of the anxiety and should be considered only if other non-pharmacological interventions are ineffective.

5. A client with depression remains in bed most of the day, declines activities, and refuses meals. Which nursing problem has the greatest priority for this client?

• A. Loss of interest in diversional activities.
• B. Social isolation.
• C. Refusal to address nutritional needs.
• D. Low self-esteem.

Correct answer: C

Rationale: The correct answer is C: 'Refusal to address nutritional needs.' In this scenario, the client's refusal to eat and address their nutritional needs poses an immediate threat to their physical health. Without proper nutrition, the client is at risk of malnutrition and its associated complications. While addressing social isolation, low self-esteem, and loss of interest in diversional activities are important aspects of holistic care for a client with depression, ensuring proper nutrition takes precedence due to the critical impact it has on the client's physical well-being. Therefore, the priority is to address the client's refusal to eat and address their nutritional needs to prevent further deterioration of their health.

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