Nursing Elites

1. Several clients with chronic mental illness and multiple substance abuse histories live in a group residential home and attend a daycare mental health facility where group and individual therapies are provided. The RN finds the common bathroom at the facility with sputum on the walls, urine in the sink and on the floors, and the toilet stopped up with tissue, paper towels, and feces. What is the priority issue that the RN should address?

• A. Medication non-compliance.
• B. Number of bathroom facilities.
• C. Infection control.
• D. Acting out behaviors.

Correct answer: C

Rationale: The priority issue that the RN should address is infection control. The unsanitary conditions in the bathroom, with sputum on the walls, urine in the sink and on the floors, and the toilet clogged with tissue, paper towels, and feces, pose a significant health risk to all residents and staff. Addressing infection control is crucial to prevent the spread of diseases and ensure the well-being of everyone in the facility. Medication non-compliance is important but not the priority in this situation. The number of bathroom facilities, while relevant, is not the immediate concern when faced with unsanitary conditions. Acting out behaviors, though a valid concern in mental health settings, are not the priority when faced with such unsanitary and potentially infectious conditions.

2. A client is responding to auditory hallucinations and shakes a fist at a nurse and says, 'Back off, witch!' The nurse follows the client into the day room. What action should the nurse implement?

• A. Sit down in a chair near the client.
• B. Position self within an arm's length of the client.
• C. Ensure that there is physical space between the nurse and client.
• D. Move to a position that allows the client to be closest to the room's door.

Correct answer: C

Rationale: In situations where a client is responding to auditory hallucinations and displaying aggressive behavior, it is crucial for the nurse to ensure physical space between themselves and the client. This action can help de-escalate the situation and prevent any potential harm to both the nurse and the client. Sitting down near the client (Choice A) may escalate the situation by invading the client's personal space. Positioning oneself within an arm's length of the client (Choice B) may increase the risk of physical confrontation. Moving closer to the room's door (Choice D) may not be appropriate as it can block the client's exit route and escalate the situation further. Therefore, ensuring physical space between the nurse and the client (Choice C) is the most appropriate action to promote safety and prevent escalation.

3. A client in a long-term care facility who has multiple sclerosis is embarrassed about the need to use a wheelchair and the muscle spasms that are readily visible in her legs. Which approach is therapeutic in assisting the client to cope?

• A. Keep the client in her room as much as possible
• B. Assist the client with all activities of daily living
• C. Tell the client that many of the people in the facility have these same sorts of problems
• D. Encourage and praise perseverance in performing ADLs, and assist the client to dress and groom daily

Correct answer: D

Rationale: Encouraging and praising the client's perseverance in performing activities of daily living (ADLs) is therapeutic as it helps the client maintain a sense of normalcy and dignity, thus supporting their psychosocial well-being. This approach acknowledges the client's struggles while empowering them to maintain their independence and self-care. Choices A and C are incorrect as they do not address the client's emotional needs and may contribute to further isolation and distress. Choice B, while important, does not specifically address the client's feelings of embarrassment and the need for emotional support.

4. A middle-aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and low motivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning?

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

Correct answer: B

Rationale: Teaching the client to develop a plan for daily structured activities is the most effective intervention in this case. Creating a routine can help improve motivation and provide a sense of accomplishment, aiding in the recovery process. Option A, providing education on methods to enhance sleep, may address hypersomnia but does not directly target psychomotor retardation and low motivation. Option C, suggesting the client develop a list of pleasurable activities, may not address the need for structure and routine. Option D, encouraging the client to exercise, is beneficial but may not be as effective as creating a structured daily plan to address the client's specific symptoms.

5. A nurse is caring for a client with depression who is prescribed fluoxetine (Prozac). The client reports difficulty sleeping. What is the most appropriate nursing intervention?

• A. Encourage the client to take short naps during the day.
• B. Suggest the client drink a warm beverage before bedtime.
• C. Recommend the client exercise immediately before bedtime.
• D. Advise the client to take a sleep aid nightly.

Correct answer: B

Rationale: The most appropriate nursing intervention for a client with difficulty sleeping due to depression and prescribed fluoxetine is to suggest the client drink a warm beverage before bedtime. This intervention can promote relaxation and help establish a bedtime routine, potentially improving sleep quality. Encouraging short naps during the day (Choice A) may disrupt the client's nighttime sleep schedule. Recommending exercise immediately before bedtime (Choice C) can have a stimulating effect, making it harder for the client to fall asleep. Advising the client to take a sleep aid nightly (Choice D) should only be done under the guidance of a healthcare provider due to potential interactions with fluoxetine.

Similar Questions