Nursing Elites

1. A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit’s day room. What action should the nurse implement first?

• A. Administer a PRN sedative.
• B. Sit in the chair next to the client.
• C. Escort the client to his room.
• D. Listen to what the client is saying.

Correct answer: D

Rationale: When dealing with a client experiencing auditory hallucinations, it is crucial for the nurse to first listen to what the client is saying. Auditory hallucinations may hold significance to the client, and by actively listening, the nurse can gather information about the content and context of the hallucinations. This information helps the nurse assess the client's current state, emotional responses, and the potential triggers for the behavior. Administering a PRN sedative (Choice A) should not be the initial action as it may suppress important information and feelings the client is trying to communicate. Sitting next to the client (Choice B) may not be appropriate without understanding the situation better. Escorting the client to his room (Choice C) may escalate the situation without addressing the underlying cause of the behavior, which can be better understood through active listening.

2. A client on the mental health unit is becoming more agitated, shouting at the staff, and pacing in the hallway. When a PRN medication is offered, the client refuses the medication and defiantly sits on the floor in the middle of the unit hallway. What nursing intervention should the nurse implement first?

• A. Transport the client to the seclusion room.
• B. Quietly approach the client with additional staff members.
• C. Take other clients in the area to the client lounge.
• D. Administer medication to chemically restrain the client.

Correct answer: B

Rationale: In situations where a client is agitated and refusing medication, a non-confrontational approach with additional staff can help de-escalate the situation and address the client's behavior safely. Transporting the client to the seclusion room (Choice A) should not be the initial intervention unless the client poses an immediate risk of harm to themselves or others. Taking other clients to the client lounge (Choice C) does not directly address the agitated client's behavior. Administering medication to chemically restrain the client (Choice D) should only be considered after other de-escalation attempts have been made and if there is a significant safety concern.

3. The nurse is completing the admission assessment of an underweight adolescent admitted to the psychiatric unit with a diagnosis of depression. Which finding requires notification to the healthcare provider?

• A. Body mass index of 21
• B. Potassium level of 2.9 mEq/dL
• C. WBC count of 10,000/mm3
• D. Blood pressure of 110/70 mmHg

Correct answer: B

Rationale: The correct answer is B. A potassium level of 2.9 mEq/dL is critically low and requires immediate notification to the healthcare provider as it indicates a potential electrolyte imbalance, which can lead to serious cardiac arrhythmias and other complications. Choices A, C, and D are within normal ranges or not indicative of immediate life-threatening issues. A body mass index of 21 may be considered normal for some individuals, a WBC count of 10,000/mm3 is slightly elevated but not an urgent concern, and a blood pressure of 110/70 mmHg is within normal limits for an adolescent.

4. The nurse is assessing a client who has schizophrenia and is exhibiting symptoms of paranoia. Which behavior would the nurse most likely observe?

• A. The client is seen as unmotivated and withdrawn.
• B. The client is preoccupied with a fear of being harmed.
• C. The client displays a blunted affect and lacks emotional response.
• D. The client avoids group activities and shows decreased appetite.

Correct answer: B

Rationale: In clients with paranoia, they typically exhibit an intense fear of being harmed, persecuted, or targeted by others. This fear often dominates their thoughts and can significantly impact their daily functioning and interactions. Choice A, being unmotivated and withdrawn, is more indicative of negative symptoms of schizophrenia, such as avolition and social withdrawal. Choice C, displaying a blunted affect and lacking emotional response, is associated with flat affect, a symptom commonly seen in schizophrenia but not specific to paranoia. Choice D, avoiding group activities and showing decreased appetite, may be related to various symptoms or side effects, but it is not a defining characteristic of paranoia in schizophrenia.

5. A client with alcohol use disorder is being treated in a rehabilitation facility. Which behavior indicates that the client is making progress in recovery?

• A. Attends all scheduled therapy sessions regularly.
• B. Is participating in group therapy and sharing experiences.
• C. Completes a work-study program.
• D. Has a decreased need for psychiatric medication.

Correct answer: B

Rationale: The correct answer is B. Participation in group therapy and sharing experiences is a positive sign of progress in recovery for a client with alcohol use disorder. It fosters peer support, allows for personal insight, and encourages social interaction, which are essential aspects of the recovery process. Attending all scheduled therapy sessions regularly (Choice A) is important but may not necessarily indicate the same level of progress as active participation in group therapy. Completing a work-study program (Choice C) is not directly related to the client's recovery from alcohol use disorder. Having a decreased need for psychiatric medication (Choice D) is not necessarily a reliable indicator of progress in recovery from alcohol use disorder, as medication management is a separate aspect of treatment.

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