Nursing Elites

1. A male client with schizophrenia tells the nurse that the FBI is monitoring his phone calls. What is the nurse's best response?

• A. Let's talk about your feelings of being monitored.
• B. There is no evidence that the FBI is monitoring your calls.
• C. Why do you think the FBI is interested in your phone calls?
• D. I can assure you that your phone calls are not being monitored.

Correct answer: A

Rationale: The correct response is to choose A: 'Let's talk about your feelings of being monitored.' This response shows empathy and encourages the client to express his feelings. Engaging the client in a discussion about his feelings can help address underlying fears without directly challenging the delusion. Choice B is incorrect because directly denying the delusion may lead to increased distrust or agitation in the client. Choice C may come across as confrontational, which can exacerbate the client's paranoia. Choice D offers a false sense of assurance and does not address the client's concerns effectively.

2. The RN is providing care for a client diagnosed with borderline personality disorder who has self-inflicted lacerations on the abdomen. Which approach should the RN use when changing this client's dressing?

• A. Provide detailed explanations during wound cleansing.
• B. Perform the dressing change in a non-judgmental manner.
• C. Ask the client non-threateningly why they cut their abdomen.
• D. Request assistance from another staff member for the dressing change.

Correct answer: B

Rationale: Performing the dressing change in a non-judgmental manner is crucial when caring for a client with borderline personality disorder who has self-inflicted injuries. This approach helps build trust, reduces feelings of shame or guilt, and fosters a therapeutic relationship. Choice A is incorrect because while detailed explanations may be necessary, the focus should be on the non-judgmental approach. Choice C is inappropriate as it may come across as accusatory or threatening, potentially worsening the client's emotional state. Choice D is not the best option as the RN should strive to handle the situation themselves in a supportive and empathetic manner.

3. The nurse observes a female client with schizophrenia watching the news on TV. She begins to laugh softly and says, 'Yes, my love, I'll do it.' When the nurse questions the client about her comment, she states, 'The news commentator is my lover, and he speaks to me each evening. Only I can understand what he says.' What is the best response for the nurse to make?

• A. What do you believe the news commentator said to you?
• B. Let's watch the news on a different television channel.
• C. Does the news commentator have plans to harm you or others?
• D. The news commentator is not talking to you.

Correct answer: A

Rationale: The correct response for the nurse is to ask the client, 'What do you believe the news commentator said to you?' This is important to determine the content of the auditory hallucination and understand the client's perception. Choice B is incorrect as changing the TV channel does not address the underlying issue. Choice C is incorrect as it introduces a paranoid idea that the news commentator may have harmful intentions, which is not supported by the scenario. Choice D is incorrect as it dismisses the client's belief without exploring or validating her experience.

4. At a support meeting of parents of a teenager with polysubstance dependency, a parent states, 'Each time my son tries to quit taking drugs, he gets so depressed that I'm afraid he will commit suicide.' The nurse's response should be based on which information?

• A. Addiction is a chronic, incurable disease
• B. Tolerance to the effects of drugs causes feelings of depression
• C. Feelings of depression frequently lead to drug abuse and addiction
• D. Careful monitoring should be provided during withdrawal from the drugs

Correct answer: D

Rationale: The priority is to teach the parents that their son will need monitoring and support during withdrawal to ensure that he does not attempt suicide. Option A is incorrect because addiction can be managed and treated effectively with appropriate interventions. Option B is incorrect as tolerance to drugs causing depression is not the primary concern in this scenario. Option C is incorrect as while depression can be a risk factor for drug abuse, in this case, the focus is on the son's safety during withdrawal.

5. The parents of a 14-year-old boy bring their son to the hospital. He is lethargic but responsive. The mother states, 'I think he took some of my pain pills.' During the initial assessment of the teenager, what information is most important for the nurse to obtain from the parents?

• A. If he has seemed depressed recently.
• B. If a drug overdose has ever occurred before.
• C. If he might have taken any other drugs.
• D. If he has a desire to quit taking drugs.

Correct answer: C

Rationale: In a situation where a teenager is brought to the hospital after possibly ingesting pills, the most crucial information for the nurse to obtain from the parents is whether the teenager might have taken any other drugs (C). This knowledge is vital for guiding further treatment, such as administering antagonists, making it the top priority. While information about depression (A) and previous drug overdoses (B) is valuable for treatment planning, it is not as critical as knowing all substances taken. Asking about the teenager's desire to quit taking drugs (D) is not appropriate during the acute management of a drug overdose and does not take precedence over determining what other substances might have been ingested.

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