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. During 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: The correct answer is C. It's crucial to determine if the teenager might have taken other substances besides the pain pills mentioned by the mother. This information is vital for effective treatment because knowing the full scope of substances involved helps in managing potential interactions, side effects, and the overall condition of the patient. Options A, B, and D are not as critical in the immediate assessment compared to knowing if the teenager has ingested any other drugs.

3. Which diet selection by a client who is depressed and taking the MAO inhibitor tranylcypromine sulfate (Parnate) indicates to the nurse that the client understands the dietary restrictions imposed by this medication regimen?

• A. Hamburger, French fries, and chocolate milkshake.
• B. Liver and onions, broccoli, and decaffeinated coffee.
• C. Pepperoni and cheese pizza, tossed salad, and a soft drink.
• D. Roast beef, baked potato with butter, and iced tea.

Correct answer: D

Rationale: The correct answer is (D) Roast beef, baked potato with butter, and iced tea. This diet selection indicates that the client understands the dietary restrictions imposed by taking tranylcypromine sulfate (Parnate) because it does not contain tyramine. Tyramine in foods can interact with MAO inhibitors like Parnate, leading to a hypertensive crisis, which is life-threatening. Choices (A, B, and C) contain foods high in tyramine like cheese, pepperoni, and chocolate, which are contraindicated for clients taking MAO inhibitors.

4. A male client with borderline personality disorder is manipulative and consistently attempts to violate unit rules. What is the best approach for the nurse to take?

• A. Enforce unit rules consistently with all clients.
• B. Ignore the manipulative behaviors to avoid confrontation.
• C. Provide the client with special privileges to avoid conflict.
• D. Confront the client directly about his behavior.

Correct answer: A

Rationale: The correct approach for the nurse to take when dealing with a male client with borderline personality disorder who is manipulative and consistently attempts to violate unit rules is to enforce unit rules consistently with all clients. By maintaining consistency in enforcing rules, the nurse establishes clear boundaries and provides structure, which are essential for managing manipulative behavior in clients with borderline personality disorder. Ignoring the manipulative behaviors (Choice B) may lead to the reinforcement of negative behaviors. Providing the client with special privileges (Choice C) can enable further manipulation and is not recommended. Confronting the client directly about his behavior (Choice D) may escalate the situation and is less effective than consistent rule enforcement.

5. What is the most appropriate nursing intervention for a client with obsessive-compulsive disorder (OCD) who is constantly washing her hands?

• A. Allow the client to continue washing her hands.
• B. Set limits on the time spent washing her hands.
• C. Encourage the client to wash her hands less frequently.
• D. Assist the client in finding alternative ways to reduce anxiety.

Correct answer: D

Rationale: Assisting the client in finding alternative ways to reduce anxiety is the most appropriate intervention for a client with OCD who is constantly washing her hands. This approach helps address the underlying cause of the compulsive behavior by focusing on reducing anxiety rather than reinforcing the behavior. Allowing the client to continue washing her hands (choice A) would not address the root of the issue and may perpetuate the behavior. Setting limits on the time spent washing hands (choice B) may cause distress to the client and does not address the core problem. Encouraging the client to wash her hands less frequently (choice C) does not provide effective coping strategies for managing anxiety associated with OCD.

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