Nursing Elites

1. The nurse accepts a transfer to the mental health unit and understands that the client is distractible and is exhibiting a decreased ability to concentrate. The nurse has only 15 minutes to talk with the client. To develop a treatment plan for this client, which assessment is most important for the nurse to obtain?

• A. Motivation for treatment
• B. History of substance use
• C. Medication compliance
• D. Mental status examination

Correct answer: D

Rationale: A mental status examination is the most important assessment for the nurse to obtain in this scenario. It provides a comprehensive view of the client's current cognitive functioning, including their level of alertness, orientation, memory, attention, and thought process. Understanding the client's mental status is crucial for developing an appropriate treatment plan. The other options, such as motivation for treatment, history of substance use, and medication compliance, are important aspects to consider but may not directly address the client's current cognitive state and immediate treatment needs as effectively as a mental status examination.

2. The nurse is developing unit policies that will include nursing guidelines for maintaining a therapeutic milieu. Which interventions should be included when providing a therapeutic milieu in an inpatient setting?

• A. Opportunities to contribute to one's treatment plan.
• B. One-on-one dialogue sessions with the therapist.
• C. Regularly scheduled unit activities for peer interaction.
• D. Home visits to reintegrate into the family.

Correct answer: C

Rationale: The nurse is responsible for maintaining a therapeutic milieu in an inpatient setting, which involves creating a secure and structured environment that promotes client safety and offers opportunities for clients to learn healthy coping skills. Regularly scheduled unit activities for peer interaction help foster socialization, support, and a sense of community among clients. Choices A and B are valuable interventions in mental health care but do not directly relate to creating a therapeutic milieu in an inpatient setting. Choice D, home visits, would typically occur post-discharge and focus on community reintegration, rather than maintaining a therapeutic milieu within the inpatient setting.

3. The nurse is assessing a client who has schizophrenia and is exhibiting symptoms of paranoia. Which behavior would the nurse most likely observe?

• A. The client is seen as unmotivated and withdrawn.
• B. The client is preoccupied with a fear of being harmed.
• C. The client displays a blunted affect and lacks emotional response.
• D. The client avoids group activities and shows decreased appetite.

Correct answer: B

Rationale: In clients with paranoia, they typically exhibit an intense fear of being harmed, persecuted, or targeted by others. This fear often dominates their thoughts and can significantly impact their daily functioning and interactions. Choice A, being unmotivated and withdrawn, is more indicative of negative symptoms of schizophrenia, such as avolition and social withdrawal. Choice C, displaying a blunted affect and lacking emotional response, is associated with flat affect, a symptom commonly seen in schizophrenia but not specific to paranoia. Choice D, avoiding group activities and showing decreased appetite, may be related to various symptoms or side effects, but it is not a defining characteristic of paranoia in schizophrenia.

4. A male client with schizophrenia tells the RN that he is being watched and that the television is speaking directly to him. Which response by the RN is appropriate?

• A. “The television cannot speak to you.”
• B. “That sounds very frightening for you.”
• C. “You should ignore the television.”
• D. “Why do you think the television is talking to you?”

Correct answer: B

Rationale: Option B is the correct response because it acknowledges the client's feelings and demonstrates empathy. By stating that the situation sounds frightening, the RN validates the client's experience without denying or reinforcing the delusion. This approach helps build rapport and trust with the client, which is essential in therapeutic communication. Options A and C are dismissive and may invalidate the client's experience, potentially worsening the trust relationship. Option D is confrontational and may make the client defensive, hindering effective communication and rapport-building.

5. A female client engages in repeated checks of door and window locks, behavior that prevents her from arriving on time and interferes with her ability to function effectively. What action should the nurse take?

• A. Discuss why the client checks the locks frequently
• B. Ask the client why she checks the locks
• C. Plan a daily list of activities to be carried out
• D. Determine the type and size of the locks

Correct answer: B

Rationale: The correct action for the nurse to take is to ask the client why she checks the locks. By doing so, the nurse can help the client gain insight into the underlying anxiety that drives this behavior and assist her in developing new adaptive coping strategies. Choice A is not as effective as directly asking the client about her behavior. Choice C focuses on planning activities but does not address the root cause of the client's behavior. Choice D is irrelevant to addressing the client's repeated checking behavior.

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