Nursing Elites

1. A nurse is planning care for several clients attending community-based mental health programs. Which of the following clients should the nurse visit first?

• A. A client who received a burn on the arm while using a hot iron at home
• B. A client who requests a change of antipsychotic medication due to new adverse effects
• C. A client who reports hearing a voice saying that life is not worth living anymore
• D. A client who tells the nurse about experiencing manifestations of severe anxiety before and during a job interview

Correct answer: C

Rationale: The nurse should visit the client who reports hearing a voice saying that life is not worth living anymore first. This statement indicates potential suicidal ideation, which requires immediate intervention to ensure the client's safety. Choices A, B, and D do not present an immediate threat to the client's life. While burns, adverse effects of medication, and severe anxiety are important concerns, they do not pose an immediate risk of self-harm or suicide.

2. When a patient with schizophrenia is taking haloperidol, what is a priority assessment for the nurse?

• A. Assessing for signs of tardive dyskinesia
• B. Monitoring for signs of neuroleptic malignant syndrome
• C. Checking for signs of depression
• D. Monitoring for changes in appetite

Correct answer: B

Rationale: Monitoring for signs of neuroleptic malignant syndrome is crucial for patients taking haloperidol. Neuroleptic malignant syndrome is a rare but serious side effect that can occur with antipsychotic medications like haloperidol. It presents with symptoms such as high fever, unstable blood pressure, confusion, muscle rigidity, and autonomic dysfunction. Early detection and intervention are essential to prevent serious complications.

3. In an outpatient mental health clinic, a nurse is preparing to conduct an initial client interview. Which of the following actions should the nurse identify as a priority?

• A. Coordinate holistic care with social services
• B. Identify the client’s perception of their mental health status
• C. Include the client’s family in the interview
• D. Educate the client about their current mental health disorder

Correct answer: B

Rationale: During an initial client interview in a mental health clinic, it is essential for the nurse to prioritize identifying the client’s perception of their mental health status. Understanding how the client views their mental health can provide valuable insights into their condition, concerns, and needs, facilitating the development of a tailored and effective care plan. Coordinating holistic care with social services, including the client’s family in the interview, and educating the client about their current mental health disorder are important aspects of care but may not be the priority during the initial interview, where understanding the client's own perspective is crucial.

4. A client tells a nurse, 'Don’t tell anyone, but I hid a sharp knife under my mattress to protect myself from my threatening roommate.' Which of the following actions should the nurse take?

• A. Keep the client’s communication confidential, but talk to the client daily using therapeutic communication to convince them to admit to hiding the knife
• B. Keep the client’s communication confidential, but watch the client and their roommate closely
• C. Tell the client that this must be reported to the health care team because it concerns the health and safety of the client and others
• D. Report the incident to the health care team but do not inform the client of the intention to do so

Correct answer: C

Rationale: In this scenario, the nurse must prioritize the safety of the client and others. The client's disclosure of hiding a sharp knife under the mattress poses a significant risk. It is crucial for the nurse to inform the health care team about this situation to ensure immediate intervention and prevent any harm. Confidentiality is important in nursing care, but in cases where there is a clear threat to safety, the duty to protect overrides the duty of confidentiality. Reporting the incident to the health care team is essential to address the safety concerns and provide appropriate support and intervention for the client. Choices A and B are incorrect because while confidentiality is important, the immediate safety concern outweighs keeping the client's communication confidential or simply monitoring the situation. Choice D is incorrect as it does not involve informing the client, which can impact the therapeutic relationship and trust between the nurse and the client.

5. A client has a new prescription for disulfiram for the treatment of alcohol use disorder. The nurse informs the client that this medication can cause nausea and vomiting when alcohol is consumed. Which of the following types of treatment is this method an example of?

• A. Aversion therapy
• B. Flooding
• C. Biofeedback
• D. Dialectical behavior therapy

Correct answer: A

Rationale: Aversion therapy is a form of behavioral therapy that aims to create a negative response to a stimulus, in this case, alcohol consumption. Disulfiram is used in aversion therapy to induce unpleasant effects when alcohol is consumed, such as nausea and vomiting, to deter the individual from drinking. Therefore, the use of disulfiram in this context exemplifies aversion therapy. Flooding involves exposing an individual to a feared object or situation to overcome anxiety; biofeedback teaches self-regulation techniques, and dialectical behavior therapy is a type of cognitive-behavioral therapy focusing on acceptance and change strategies, which are not directly related to the use of disulfiram for alcohol use disorder.

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