Nursing Elites

1. The client is 5 feet from the bathroom door when he states, 'I feel faint.' Before the nurse can get the client to a chair, the client starts to fall. What is the priority action for the nurse to take?

• A. Check the client's carotid pulse
• B. Encourage the client to get to the toilet
• C. In a loud voice, call for help
• D. Gently lower the client to the floor

Correct answer: D

Rationale: The priority action for the nurse is to gently lower the client to the floor (Option D). This action is crucial to prevent injury to both the client and the nurse. Lowering the client to the floor should be done when the client is unable to support his own weight, ensuring a safe position to prevent falls. Checking the client's carotid pulse (Option A) is important, but it should be performed after ensuring the client's safety. Encouraging the client to get to the toilet (Option B) is impractical as the client is already falling. Calling for help in a loud voice (Option C) may cause chaos and alarm other clients, making it a less suitable immediate action in this scenario.

2. What action would be most appropriate for the nurse to minimize agitation in a disturbed client?

• A. Ensure minimal staff contact.
• B. Increase environmental sensory stimulation.
• C. Limit unnecessary interactions with the client.
• D. Discuss reasons for the client's suspicions.

Correct answer: C

Rationale: The most appropriate action to minimize agitation in a disturbed client is to limit unnecessary interactions. This approach helps reduce stimulation, thus decreasing agitation. Constant staff contact can lead to increased stimulation and agitation. Increasing environmental sensory stimulation can overwhelm the client's senses and escalate agitation. Discussing suspicions may not be beneficial as not all disturbed clients are suspicious and the client may not be in a state to engage in such discussions effectively.

3. Which of these is a one-on-one communication between the nurse and another person?

• A. Small-group communication
• B. Intrapersonal communication
• C. Interpersonal communication
• D. Transpersonal communication

Correct answer: C

Rationale: Interpersonal communication is a one-on-one interaction between a nurse and another person that often occurs face-to-face. It involves direct communication between two individuals. Small-group communication involves interaction among a small number of people, not just one-on-one. Intrapersonal communication is internal communication that occurs within an individual's mind. Transpersonal communication involves interactions within a person's spiritual domain, which is beyond individual one-on-one communication.

4. What factor is likely the reason a woman with bipolar disorder, manic episode, rarely eats?

• A. Feelings of guilt
• B. Need to control others
• C. Desire for punishment
• D. Excessive physical activity

Correct answer: D

Rationale: During a manic episode of bipolar disorder, individuals often experience hyperactivity and an inability to stay still. This hyperactivity can manifest as excessive physical activity, which can prevent them from eating regularly. The correct answer is 'Excessive physical activity' because it directly relates to the woman's lack of appetite during the manic episode. Feelings of guilt, the need to control others, and the desire for punishment are not typically associated with eating difficulties in individuals with bipolar disorder during a manic episode. Clients in a manic episode usually have heightened energy levels and may engage in activities that exhaust them, leading to a decreased focus on eating.

5. What approach should the nurse use when a manipulative client who uses acting-out behaviors asks the nurse to talk while the nurse is orienting a new client to the unit?

• A. Suggest that the client requesting attention speak with another staff member.
• B. Leave the new client, saying, 'I'll talk with the other client until things calm down.'
• C. Introduce the two clients and suggest that the client join them on a tour of the facility.
• D. Say to the interrupting client, 'I'll be back to talk with you after I orient this new client.'

Correct answer: D

Rationale: The nurse should respond to the manipulative client who uses acting-out behaviors by setting realistic limits on behavior without rejecting the client. Therefore, the correct approach is to say to the interrupting client, 'I'll be back to talk with you after I orient this new client.' This response acknowledges the client's request while prioritizing the needs of the new client and setting appropriate boundaries. Choices A, B, and C are incorrect. Suggesting that the client speak with another staff member would be a rejection of the client, not the behavior. Leaving the new client to attend to the manipulative client would encourage further manipulation and disrupt the orientation process for the new client. Introducing the two clients and suggesting a tour is inconsistent with setting limits and does not address the manipulative behavior being displayed.

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