Nursing Elites

1. A client is being educated by a healthcare professional about initiating a prescribed abstinence therapy using Disulfiram (Antabuse). What information should the client acknowledge understanding?

• A. Admit to others that they are a substance abuser.
• B. Remain alcohol-free for 12 hours before taking the first dose.
• C. Attend monthly Alcoholics Anonymous meetings.
• D. Completely abstain from heroin or cocaine use.

Correct answer: B

Rationale: B: Before starting Disulfiram therapy, it is crucial for clients to be alcohol-free for a minimum of 12 hours to prevent adverse reactions. A: Admitting substance abuse is important, but it is not directly linked to the initiation of Disulfiram therapy. C: Attending Alcoholics Anonymous meetings is beneficial for support but not a specific requirement for starting Disulfiram. D: The focus of Disulfiram therapy is on alcohol abstinence, so abstaining from heroin or cocaine is not directly related to this medication.

2. A client who recently experienced the death of a significant other arrives at the mental health center. The client reports loss of interest in usual activities, expresses a wish to be with the deceased significant other, has been eating very little, and has not slept in several days. Which client statement is most important for the RN to explore at this time?

• A. Not sleeping for several days.
• B. Wishing to be with the deceased significant other.
• C. Lack of interest in usual activities.
• D. Eating very little.

Correct answer: A

Rationale: The most important client statement for the RN to explore in this scenario is the client not sleeping for several days. The lack of sleep is a critical indicator of possible severe depression or suicidal ideation that requires immediate attention. While expressing a wish to be with the deceased significant other, having a lack of interest in usual activities, and eating very little are concerning, the immediate focus should be on the client's severe sleep disturbance as it can pose an immediate risk to their well-being and safety.

3. While working with a male client at a community mental health center, the client reports hearing voices that tell him to get a knife from the kitchen and hurt himself. What intervention is most important for the RN to implement?

• A. Prevent the client from going into the kitchen until the hallucination subsides.
• B. Report the behavior to the client’s case worker to inform the family.
• C. Assign a UAP to stay with the client continually.
• D. Document the behavior in the client’s record and notify the HCP.

Correct answer: A

Rationale: The most crucial intervention for the RN to implement in this scenario is to prevent the client from accessing the kitchen where potential means of self-harm are available until the hallucination subsides. This immediate action is necessary to ensure the client's safety. While reporting the behavior to the client's case worker for further support is important, addressing the immediate risk of harm takes precedence. Assigning a UAP to stay with the client continually is valuable for ongoing monitoring but is secondary to ensuring immediate safety. Documenting the behavior in the client's record and notifying the healthcare provider are essential steps in the care process; however, they should follow actions taken to ensure the client's immediate safety.

4. While interviewing a client, the nurse takes notes to assist with accurate documentation later. Which statement is most accurate regarding note-taking during an interview?

• A. The client’s comfort level is increased when the nurse maintains eye contact while taking notes.
• B. The interview process is enhanced with note-taking, allowing the client to speak at a normal pace.
• C. Note-taking during an interview is not a legal obligation of the examining nurse.
• D. The nurse’s ability to directly observe the client’s nonverbal communication is limited with note-taking.

Correct answer: D

Rationale: During an interview, note-taking can hinder the nurse’s ability to directly observe the client's nonverbal cues such as body language, facial expressions, and tone of voice. These nonverbal cues are crucial for understanding the client's emotions, feelings, and overall communication. Therefore, it is essential for the nurse to strike a balance between note-taking for documentation purposes and actively observing the client's nonverbal communication to ensure a comprehensive assessment. Choices A, B, and C are incorrect because maintaining eye contact, enhancing the interview process with note-taking, and legal obligations of note-taking during an interview do not directly address the issue of limited observation of nonverbal communication while taking notes.

5. What intervention is likely to be most effective in returning a middle-aged adult with major depressive disorder who suffers from psychomotor retardation, hypersomnia, and amotivation to a normal level of functioning?

• A. Encourage the client to exercise.
• B. Suggest that the client develop a list of pleasurable activities.
• C. Provide education on methods to enhance sleep.
• D. Teach the client to develop a plan for daily structured activities.

Correct answer: D

Rationale: The most effective intervention for a middle-aged adult with major depressive disorder experiencing psychomotor retardation, hypersomnia, and amotivation is to teach the client to develop a plan for daily structured activities. This intervention helps combat the symptoms by providing a routine and purpose to the client's day, addressing the issues of psychomotor retardation and amotivation. Structured activities can help establish a sense of normalcy, improve motivation, and regulate sleep patterns. Encouraging exercise (Choice A) can be beneficial but may be challenging for a client experiencing psychomotor retardation. Developing a list of pleasurable activities (Choice B) may not address the need for structure and routine in the client's daily life. Providing education on sleep enhancement methods (Choice C) is important but may not be sufficient to address the overall functional impairment in this case.

Similar Questions