Nursing Elites

1. 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.

2. The healthcare provider is assessing a client who has been taking an antidepressant for several months. Which symptom would suggest that the medication is working?

• A. Improved mood and increased energy.
• B. Increased appetite and weight gain.
• C. Decreased anxiety and agitation.
• D. Enhanced sleep patterns and vivid dreams.

Correct answer: A

Rationale: When assessing the effectiveness of an antidepressant, improved mood and increased energy are positive indicators that the medication is working. Choice B, increased appetite and weight gain, are more commonly associated with side effects of some antidepressants, such as certain tricyclic antidepressants. Choice C, decreased anxiety and agitation, could be related to the therapeutic effects of antidepressants in treating anxiety disorders but may not specifically indicate the efficacy of the medication for depression. Choice D, enhanced sleep patterns and vivid dreams, while changes in sleep patterns can be influenced by antidepressants, they are not the primary indicators of antidepressant efficacy. Therefore, the correct choice is A as it directly reflects the desired outcomes of antidepressant therapy.

3. A female client on a psychiatric unit is sweating profusely while vigorously doing push-ups and then running the length of the corridor several times before crashing into furniture in the sitting room. Picking herself up, she begins to verbally attack other clients. What intervention is most appropriate for the RN to use to manage the client’s behavior?

• A. Assist the client to a safe area to avoid injury.
• B. Establish clear and firm limits with the client.
• C. Offer medication to help calm the client down.
• D. Speak with the client in a calm, non-threatening manner.

Correct answer: A

Rationale: Assisting the client to a safe area is the most appropriate intervention in this scenario. This action helps prevent injury to the client and others while allowing for de-escalation in a controlled environment. While establishing clear and firm limits (Choice B) may be necessary in some situations, the immediate priority here is safety. Offering medication (Choice C) should not be the first response unless the situation escalates further and poses a risk to the client or others. Speaking with the client in a calm, non-threatening manner (Choice D) may not be effective when the client is in an agitated state and engaging in risky behavior.

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. A mental health worker is caring for a client with escalating aggressive behavior. Which action by the mental health worker warrants immediate intervention by the RN?

• A. Attempting to physically restrain the client.
• B. Remaining at a distance of 4 feet from the client.
• C. Telling the client to go to the quiet area of the unit.
• D. Using a loud voice to communicate with the client.

Correct answer: A

Rationale: Attempting to physically restrain the client without proper protocol and preparation can escalate the situation. This can lead to increased agitation and aggression in the client, potentially putting both the client and the mental health worker at risk. Remaining at a distance, directing the client to a quiet area, or using a loud voice are all strategies that can be used to de-escalate the situation and ensure safety without resorting to physical intervention. Therefore, the immediate intervention is needed when the mental health worker attempts to physically restrain the client. Option B, remaining at a distance, is a safe practice to ensure personal safety. Option C, directing the client to a quiet area, is a de-escalation technique to create a calmer environment. Option D, using a loud voice, may be necessary to establish boundaries and ensure the client can hear instructions clearly.

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