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. 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.

3. 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 should the nurse do first?

• A. Offer the client a safe place to relax before interviewing her.
• B. Ask the client to describe why she is being stalked.
• C. Recommend that the client talk with a social worker.
• D. Assure the client that the healthcare provider will see her today.

Correct answer: A

Rationale: When a client presents with signs of distress and potential safety concerns, the priority is to provide a safe environment. Offering a safe place to relax can help the client feel secure and ready for further assessment and support. This action allows the nurse to establish rapport, ensure the client's immediate safety, and create a trusting relationship before delving into the details of the situation. Asking the client to describe why she is being stalked (Choice B) may exacerbate her distress and should come after ensuring her safety. Recommending that the client talk with a social worker (Choice C) is important but should follow immediate safety measures. Assuring the client that the healthcare provider will see her today (Choice D) is less critical than addressing her safety concerns and emotional state.

4. A client who has agoraphobia (a fear of crowds) is starting desensitization therapy with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care?

• A. Encourage the substitution of positive thoughts for negative ones.
• B. Establish trust by providing a calm, safe environment.
• C. Gradually expose the client to larger crowds.
• D. Encourage deep breathing when anxiety escalates in a crowd.

Correct answer: B

Rationale: Establishing trust by providing a calm and safe environment is crucial for the success of desensitization therapy in clients with agoraphobia. This approach helps the client feel safe and secure, allowing them to gradually confront their fear of crowds. Encouraging positive thoughts (choice A) is beneficial but not as immediately critical as creating a safe space. Progressively exposing the client to larger crowds (choice C) should occur after trust is established and in a controlled manner. Encouraging deep breathing (choice D) is helpful, but creating a safe environment takes precedence to build a foundation for successful desensitization.

5. A male adolescent was admitted to the unit two days ago for depression. When the mental health nurse tries to interview the client to establish rapport, he becomes very irritated and sarcastic. Which action is best for the nurse to take?

• A. Offer to play a game of cards with the client.
• B. Report the behavior to the next shift.
• C. Document the behavior in the chart.
• D. Plan to talk with the client the next day.

Correct answer: A

Rationale: Offering to play a game of cards with the adolescent is the best action for the nurse to take in this situation. Engaging in an activity like playing a game can help establish rapport with the adolescent as it provides a more relaxed and non-threatening environment for communication. This approach can help the adolescent feel more comfortable and open up, as adolescents often find it easier to communicate when involved in an activity. Reporting the behavior to the next shift, documenting the behavior, or planning to talk with the client the next day do not directly address the immediate need to establish rapport and improve communication with the adolescent.

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