Nursing Elites

1. An adult male client who was admitted to the mental health unit yesterday tells the nurse that microchips were planted in his head for military surveillance of his every move. Which response is best for the nurse to provide?

• A. You are in the hospital, and I am the nurse caring for you
• B. It must be difficult for you to control your anxious feelings
• C. Go to occupational therapy and start a project
• D. You are not in a war area now; this is the United States

Correct answer: C

Rationale: Delusions often generate fear and isolation, so the nurse should help the client participate in activities that avoid focusing on the false belief and encourage interaction with others.

2. A client with alcohol use disorder is admitted for detoxification. The nurse should monitor for which early sign of alcohol withdrawal?

• A. Seizures
• B. Visual hallucinations
• C. Tremors
• D. Delirium tremens

Correct answer: C

Rationale: Tremors are an early sign of alcohol withdrawal. They are caused by hyperactivity of the autonomic nervous system and are a common symptom during the early stages of withdrawal. Monitoring tremors is crucial as they can progress to more severe symptoms if not managed effectively. Seizures (Choice A) typically occur later in the withdrawal process and are a more severe symptom. Visual hallucinations (Choice B) usually manifest after tremors and are considered a mid-stage symptom. Delirium tremens (Choice D) is a severe form of alcohol withdrawal that typically occurs 2-3 days after the last drink, characterized by confusion, disorientation, and severe autonomic hyperactivity.

3. A young adult male with a history of substance abuse is admitted to the psychiatric unit for detoxification. He is agitated, sweating, and reports seeing bugs crawling on the walls. What is the priority nursing intervention?

• A. Reassure the client that the bugs are not real.
• B. Administer the prescribed benzodiazepine.
• C. Place the client in a quiet, dark room.
• D. Encourage the client to express his feelings.

Correct answer: B

Rationale: The correct answer is to administer the prescribed benzodiazepine. This intervention helps manage the client's agitation and hallucinations, which are common symptoms during detoxification from substances. Reassuring the client that the bugs are not real (Choice A) may not be effective in addressing the underlying causes of the hallucinations. Placing the client in a quiet, dark room (Choice C) may help reduce sensory stimulation but does not directly address the client's symptoms. Encouraging the client to express his feelings (Choice D) is important for therapeutic communication but may not be the priority when the client is experiencing severe agitation and hallucinations.

4. When developing a plan of care for a client in the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing diagnosis has the highest priority?

• A. Risk for injury.
• B. Ineffective coping mechanisms.
• C. Alteration in comfort.
• D. Ineffective breathing patterns.

Correct answer: D

Rationale: When a client aspirates a caustic material, the priority nursing diagnosis should focus on addressing physiological concerns, particularly related to breathing patterns. Aspiration of caustic material can lead to airway compromise, respiratory distress, and potential lung damage. Therefore, monitoring and addressing ineffective breathing patterns are crucial for ensuring the client's immediate safety and well-being. Choices A, B, and C are important considerations in psychiatric care but are secondary to the critical physiological issue of ineffective breathing patterns in this scenario.

5. A RN is preparing the physical environment to interview a new client for admission to the mental health unit. Which environmental setting facilitates the best outcome of the interview?

• A. Dim the lights in the room to help the patient feel calm.
• B. Sit within two feet of the client to enhance the level of safety and security.
• C. Reduce the noise level in the room by turning off the television and radio.
• D. Position a table between the client and the RN for extra personal space.

Correct answer: C

Rationale: Reducing the noise level in the room by turning off the television and radio is the best choice among the options provided. This setting helps create a calm and focused environment, which facilitates better communication and assessment during the interview. Dimming the lights might not be suitable for all clients and could potentially hinder communication. Sitting too close or placing a table between the client and the RN may affect the client's comfort level and openness during the interview.

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