Nursing Elites

1. A male client with schizophrenia tells the nurse that the voices he hears are saying, 'You must kill yourself.' To assist the client in coping with these thoughts, which response is best for the nurse to provide?

• A. Tell yourself that the voices are unreasonable.'
• B. Exercise when you hear the voices.'
• C. Talk to someone when you hear the voices.'
• D. The voices aren't real, so ignore them.'

Correct answer: A

Rationale: The nurse should teach the client to use self-talk to disprove the voices. Although exercising may be helpful, the client's concrete thinking may make it difficult to understand this suggestion. Clients with schizophrenia have difficulty initiating interaction with others. Auditory hallucinations are often relentless, so it is difficult to ignore them.

2. A female client with post-traumatic stress disorder (PTSD) has been experiencing flashbacks. Which intervention should the nurse implement to help the client?

• A. Encourage the client to talk about the trauma.
• B. Advise the client to avoid triggers that cause flashbacks.
• C. Help the client stay grounded in the present moment.
• D. Refer the client to group therapy for PTSD.

Correct answer: C

Rationale: The correct intervention for a client with PTSD experiencing flashbacks is to help them stay grounded in the present moment. This technique can reduce the intensity of flashbacks and provide a sense of safety. Encouraging the client to talk about the trauma (Choice A) may exacerbate the symptoms and should be done cautiously under professional guidance. Advising the client to avoid triggers (Choice B) is important, but solely relying on avoidance may not address the underlying issues. Referring the client to group therapy (Choice D) can be beneficial, but in the immediate context of managing flashbacks, grounding techniques are more appropriate.

3. A female client on the psychiatric unit tells the nurse that she feels like ending her life because she can no longer deal with her depression. What is the nurse's priority intervention?

• A. Stay with the client and ensure her safety.
• B. Inform the client that she is safe in the hospital.
• C. Document the client's statements in her medical record.
• D. Encourage the client to join a group therapy session.

Correct answer: A

Rationale: The correct answer is to stay with the client and ensure her safety. Ensuring the client's safety is the top priority when a client expresses suicidal ideation. Staying with the client can help prevent self-harm while further assessment and interventions are arranged. Choice B is incorrect because simply informing the client that she is safe in the hospital does not address the immediate need for safety. Choice C is incorrect as while documentation is important, it is not the priority when a client's safety is at risk. Choice D is also incorrect as encouraging the client to join a group therapy session is not appropriate when the client is in crisis and expressing suicidal thoughts.

4. A male adolescent is admitted with bipolar disorder after being released from jail for assault with a deadly weapon. When the nurse asks the teen to identify his reason for the assault, he replies, 'Because he made me mad!' Which goal is best for the nurse to include in the client's plan of care? The client will

• A. outline methods for managing anger.
• B. control impulsive actions toward self and others.
• C. verbalize feelings when anger occurs.
• D. recognize consequences for behaviors exhibited.

Correct answer: B

Rationale: In this scenario, the client's response indicates poor impulse control, a common issue in individuals with bipolar disorder. The most critical goal for the nurse to include in the client's plan of care is to help the client control impulsive actions toward self and others. This goal is essential for preventing harmful behaviors and mitigating the social consequences associated with impulsivity. While outlining methods for managing anger, verbalizing feelings when anger occurs, and recognizing consequences for behaviors exhibited are important aspects of therapy, they do not directly address the urgent need to control impulsive behavior in this case.

5. A client with schizophrenia is being treated with haloperidol (Haldol) and begins to exhibit symptoms of tardive dyskinesia. What is the nurse's priority action?

• A. Continue the medication and monitor for worsening symptoms.
• B. Administer the next dose of haloperidol with food.
• C. Report the symptoms to the healthcare provider immediately.
• D. Educate the client about the side effects of haloperidol.

Correct answer: C

Rationale: The correct answer is to report the symptoms to the healthcare provider immediately. Tardive dyskinesia is a serious side effect of antipsychotic medications, including haloperidol. Prompt reporting is crucial to evaluate the need for medication adjustment or change in treatment. Continuing the medication without intervention (choice A) can worsen the symptoms. Administering the next dose (choice B) is not appropriate when tardive dyskinesia is suspected. Educating the client (choice D) is important but not the priority when dealing with acute symptoms of tardive dyskinesia.

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