Nursing Elites

1. A mental health worker is caring for a client with escalating aggressive behavior. Which action by the mental health worker warrants immediate intervention by the RN?

• A. Attempting to physically restrain the client.
• B. Remaining at a distance of 4 feet from the client.
• C. Telling the client to go to the quiet area of the unit.
• D. Using a loud voice to communicate with the client.

Correct answer: A

Rationale: Attempting to physically restrain the client without proper protocol and preparation can escalate the situation. This can lead to increased agitation and aggression in the client, potentially putting both the client and the mental health worker at risk. Remaining at a distance, directing the client to a quiet area, or using a loud voice are all strategies that can be used to de-escalate the situation and ensure safety without resorting to physical intervention. Therefore, the immediate intervention is needed when the mental health worker attempts to physically restrain the client. Option B, remaining at a distance, is a safe practice to ensure personal safety. Option C, directing the client to a quiet area, is a de-escalation technique to create a calmer environment. Option D, using a loud voice, may be necessary to establish boundaries and ensure the client can hear instructions clearly.

2. During an annual physical at the corporate clinic, a male employee expresses to the RN that his high-stress job is causing trouble in his personal life. He mentions getting so angry while driving to and from work that he has considered 'getting even' with other drivers. How should the RN respond?

• A. “Anger is contagious and could lead to major confrontations.”
• B. “Try not to let your anger cause you to act impulsively.”
• C. “Expressing your anger to a stranger could lead to an unsafe situation.”
• D. “It seems like there are many situations that make you feel angry.”

Correct answer: B

Rationale: The correct response for the RN is to advise the employee not to act impulsively when feeling angry. This approach helps the individual learn to manage anger in a constructive manner, reducing the likelihood of potential conflicts. Choice A is incorrect because although acknowledging that anger can escalate into confrontations is valid, it does not provide immediate guidance on managing the anger. Choice C focuses on the dangers of expressing anger to strangers but does not address the core issue of managing anger. Choice D simply acknowledges the employee's feelings without providing guidance on how to address the situation effectively.

3. An elderly client is admitted to the psychiatric unit with a diagnosis of major depressive disorder. Which assessment finding is most concerning for the nurse?

• A. Weight loss of 5 pounds in one week.
• B. Lack of interest in previously enjoyed activities.
• C. Disorganized speech and thought processes.
• D. Severe fatigue and low energy levels.

Correct answer: C

Rationale: In an elderly client with major depressive disorder, disorganized speech and thought processes are the most concerning assessment findings for the nurse. These symptoms can suggest a more severe condition such as psychosis or cognitive impairment, which require immediate attention and intervention. While weight loss, lack of interest in activities, severe fatigue, and low energy levels are common symptoms of major depressive disorder, they do not pose an immediate risk as disorganized speech and thought processes do. Therefore, the nurse should prioritize addressing the disorganized speech and thought processes to ensure the safety and well-being of the client.

4. A female client on a psychiatric unit is sweating profusely while vigorously doing push-ups and then running the length of the corridor several times before crashing into furniture in the sitting room. Picking herself up, she begins to verbally attack other clients. What intervention is most appropriate for the RN to use to manage the client’s behavior?

• A. Assist the client to a safe area to avoid injury.
• B. Establish clear and firm limits with the client.
• C. Offer medication to help calm the client down.
• D. Speak with the client in a calm, non-threatening manner.

Correct answer: A

Rationale: Assisting the client to a safe area is the most appropriate intervention in this scenario. This action helps prevent injury to the client and others while allowing for de-escalation in a controlled environment. While establishing clear and firm limits (Choice B) may be necessary in some situations, the immediate priority here is safety. Offering medication (Choice C) should not be the first response unless the situation escalates further and poses a risk to the client or others. Speaking with the client in a calm, non-threatening manner (Choice D) may not be effective when the client is in an agitated state and engaging in risky behavior.

5. Narcan was administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate (Vicodin). Within 15 minutes, the client is alert and oriented. In planning nursing care, which intervention has the highest priority at this time?

• A. Encourage the client to increase fluid intake.
• B. Obtain the client’s serum Vicodin level.
• C. Observe the client for further narcotic effects.
• D. Determine the client’s reason for attempting suicide.

Correct answer: C

Rationale: Observing the client for further narcotic effects is the priority at this time. It is crucial to monitor the client closely to prevent a relapse of symptoms or potential complications from the overdose. Encouraging fluid intake is important for overall health but not the priority after an overdose. Obtaining serum Vicodin levels may be needed later but does not address the immediate need to monitor for ongoing effects. Determining the reason for the suicide attempt is vital for psychological assessment but should come after ensuring the client's physical stability.

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