Nursing Elites

1. The nurse asks a female client with borderline personality disorder, 'How do you feel about your children not coming to visit this weekend?' The client looks out the window and replies, 'I really don't care.' Which response is best for the nurse to provide?

• A. I noticed you were looking out the window when discussing your feelings.
• B. I think you're lying and it bothers you that your children aren't coming.
• C. I think you should discuss your children not coming in the group meeting.
• D. Why do you think your children didn't want to come visit you this weekend?

Correct answer: A

Rationale: Acknowledging the client's non-verbal behavior, such as looking out the window, demonstrates active listening and provides the client with an opportunity to explore their feelings further. Choice B is incorrect as it accuses the client of lying without any evidence, which can damage the therapeutic relationship. Choice C is inappropriate as it dismisses the client's feelings and suggests a group discussion without addressing the client's emotions directly. Choice D is also incorrect as it focuses on the children's actions rather than the client's feelings, missing an opportunity for therapeutic communication.

2. The community health nurse talks to a male client who has bipolar disorder. The client explains that he sleeps 4 to 5 hours a night and is working with his partner to start two new businesses and build an empire. The client stopped taking his medications several days ago. What nursing problem has the highest priority?

• A. Excessive work activity.
• B. Decreased need for sleep.
• C. Medication management.
• D. Inflated self-esteem.

Correct answer: D

Rationale: The priority is to manage the client's medication adherence to prevent escalation of manic behavior. Inflated self-esteem is the highest priority as it indicates the client's potential for harmful behaviors due to lack of medication compliance. While excessive work activity and decreased need for sleep are characteristics of mania, they are not as immediately concerning as the risk of harm related to inflated self-esteem.

3. A nurse is caring for a client with major depressive disorder who is withdrawn and refuses to participate in group activities. What is the best nursing intervention?

• A. Encourage the client to attend at least one group session.
• B. Respect the client's wish to remain isolated.
• C. Arrange for individual therapy sessions.
• D. Offer the client a list of activities to choose from.

Correct answer: A

Rationale: Encouraging the client to attend at least one group session is the best nursing intervention in this scenario. By gently encouraging participation, the nurse can help the client start to engage with others, which may gradually improve their mood and social interaction. Choice B, respecting the client's wish to remain isolated, may further exacerbate the client's withdrawal and depression by reinforcing avoidance behavior. Choice C, arranging for individual therapy sessions, can be beneficial but may not address the specific need for social interaction. Choice D, offering a list of activities to choose from, does not directly address the client's difficulty in participating in group activities and may not provide the necessary support in overcoming social withdrawal.

4. 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.

5. Unresolved feelings related to loss are most likely to be recognized during which phase of the therapeutic nurse-client relationship?

• A. Working
• B. Trusting
• C. Orientation
• D. Termination

Correct answer: D

Rationale: Unresolved feelings related to loss are often recognized and explored during the termination phase of the nurse-client relationship. This phase involves preparing the client for separation from the nurse, which can trigger unresolved feelings related to loss. During the termination phase, clients may confront their emotions about ending the therapeutic relationship and may also revisit unresolved issues or losses that have surfaced during the course of therapy. Choices A, B, and C are incorrect because the working phase focuses on active problem-solving and goal achievement, the trusting phase emphasizes establishing rapport and building trust, and the orientation phase involves initial introductions and orientation to the therapeutic process, respectively.

Similar Questions