Nursing Elites

1. What action is most important for the RN to implement within the first 24 hours after treatment is initiated for a homeless client who reports feeling sad and depressed and has only had 4 hours of sleep in the past 2 days?

• A. Allow the client to rest and sleep.
• B. Ensure the client attends groups addressing coping skills for dealing with depression.
• C. Begin planning for the client’s discharge.
• D. Encourage verbalization of feelings.

Correct answer: A

Rationale: A: Addressing the client’s immediate need for rest and sleep is crucial for stabilization and recovery. It is essential to prioritize the client's physical well-being and provide the opportunity for adequate rest. B: Group therapy and coping skills are important but secondary to ensuring immediate needs are met. C: Discharge planning is important but should follow stabilization of the client’s immediate needs. D: Encouraging verbalization of feelings is supportive but not as urgent as addressing basic needs like rest.

2. A healthcare provider is evaluating a client's response to a new antianxiety medication. Which client statement indicates a positive response to the medication?

• A. “I feel more relaxed and less anxious.”
• B. “I am sleeping less and feel more energetic.”
• C. “I have not noticed any changes in my anxiety levels.”
• D. “I have more difficulty concentrating than before.”

Correct answer: A

Rationale: The correct answer is A: “I feel more relaxed and less anxious.” A positive response to antianxiety medication is characterized by reduced anxiety and increased relaxation. Choice B, which mentions sleeping less and feeling more energetic, suggests potential side effects rather than a positive response to the medication. Choice C indicates no change in anxiety levels, which is not indicative of a positive response. Choice D, mentioning difficulty concentrating, is also a sign of a negative response to antianxiety medication as it may suggest cognitive impairment.

3. A client is agitated and physically aggressive. What action should the RN take first?

• A. Calmly inform the client that they will be placed in seclusion if they do not calm down.
• B. Discuss with the client the reasons for their agitation and aggression.
• C. Tell the client that physical aggression is not acceptable and must stop.
• D. Seek assistance from other staff members and follow the facility’s protocol.

Correct answer: D

Rationale: In a situation where a client is agitated and physically aggressive, the priority for the RN is to ensure the safety of the client and others. Seeking assistance from other staff members is crucial as it allows for a prompt response to manage the situation effectively and according to the facility’s protocol. Choices A, B, and C do not address the immediate need for safety or involve the collaboration of other staff members, which is essential in handling aggressive behaviors in a healthcare setting.

4. A male hospital employee is pushed out of the way by a female employee because of an oncoming gurney. The pushed employee becomes very angry and swings at the female employee. Both employees are referred for counseling with the staff psychiatric nurse. Which factor in the pushed employee’s history is most related to the reaction that occurred?

• A. Is worried about losing his job to a woman.
• B. Tortured animals as a child.
• C. Was physically abused by his mother.
• D. Hates to be touched by anyone.

Correct answer: C

Rationale: The correct answer is 'C: Was physically abused by his mother.' The pushed employee's aggressive reaction can be attributed to his history of physical abuse. Research suggests that individuals who have experienced physical abuse may exhibit heightened aggressive responses due to trauma and learned behavior. Choices A, B, and D are incorrect: A is a stereotype-based assumption that does not have a direct correlation with the aggressive behavior observed; B, torturing animals, is concerning behavior but not directly linked to the aggressive response in this scenario; D, hating to be touched, is not the most relevant factor considering the situation described.

5. To evaluate the effectiveness of cognitive-behavioral techniques, which client outcomes should the nurse include in the plan of care?

• A. Relates insights into problematic relationships
• B. Demonstrates a healthy relationship with her husband
• C. Describes how the family can resolve problems
• D. Changes thought patterns related to problem-solving

Correct answer: D

Rationale: The correct answer is D. Cognitive-behavioral therapy focuses on changing thought patterns by guiding the client to engage in problem-solving strategies to address the current situation. This approach helps individuals modify negative thinking patterns and develop more adaptive ways to cope with challenges. Choices A, B, and C are incorrect because while they may be important aspects to consider in therapy, the primary focus in cognitive-behavioral therapy is on identifying and changing negative thought patterns rather than exploring relationships or family problem-solving skills.

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