Nursing Elites

1. What assessment questions should the nurse ask when attempting to determine a teenager’s mental health resilience? Select all that apply.

• A. How did you cope when your father deployed with the Army for a year in Iraq?
• B. Who did you go to for advice while your father was away for a year in Iraq?
• C. How do you feel about talking to a mental health counselor?
• D. Where do you see yourself in 10 years?

Correct answer: C

Rationale: The question 'How do you feel about talking to a mental health counselor?' is the most appropriate to assess the teenager's mental health resilience as it directly addresses their willingness to seek help and cope effectively. Choices A and B focus on coping mechanisms during a specific event, which may not reflect the teenager's overall resilience. Choice D is more related to future aspirations rather than assessing current mental health resilience.

2. A client with obsessive-compulsive disorder (OCD) is undergoing behavioral therapy. Which outcome should the nurse recognize as an indication that the client is responding positively to therapy?

• A. The client reports increased frequency of obsessive thoughts.
• B. The client demonstrates a decrease in compulsive behaviors.
• C. The client expresses a desire to leave therapy early.
• D. The client avoids participating in exposure tasks.

Correct answer: B

Rationale: A decrease in compulsive behaviors is a positive response to behavioral therapy for OCD. Behavioral therapy aims to reduce these behaviors and promote healthier coping mechanisms. Option A, reporting an increased frequency of obsessive thoughts, would indicate a lack of improvement or worsening of symptoms. Option C, expressing a desire to leave therapy early, suggests resistance or dissatisfaction with therapy. Option D, avoiding participation in exposure tasks, goes against the principles of exposure therapy, which is commonly used in OCD treatment to help clients confront their fears and reduce anxiety.

3. What assessment question will provide healthcare providers with information regarding the effects of a woman's circadian rhythms on her quality of life?

• A. How much sleep do you usually get each night?
• B. Does your heart ever seem to skip a beat?
• C. When was the last time you had a fever?
• D. Do you have problems urinating?

Correct answer: A

Rationale: Asking about the amount of sleep a woman gets each night is crucial in understanding her circadian rhythms and how they may affect her quality of life. Circadian rhythms are the body's internal clock that regulates the sleep-wake cycle. Monitoring sleep patterns can provide insights into how well these rhythms are functioning and impacting daily life. Choices B, C, and D are unrelated to circadian rhythms and do not directly assess the effects of these rhythms on quality of life.

4. A female client on a psychiatric unit is sweating profusely while vigorously doing push-ups and then running the length of the corridor several times before crashing into furniture in the sitting room. Picking herself up, she begins to verbally attack other clients. What intervention is most appropriate for the RN to use to manage the client’s behavior?

• A. Assist the client to a safe area to avoid injury.
• B. Establish clear and firm limits with the client.
• C. Offer medication to help calm the client down.
• D. Speak with the client in a calm, non-threatening manner.

Correct answer: A

Rationale: Assisting the client to a safe area is the most appropriate intervention in this scenario. This action helps prevent injury to the client and others while allowing for de-escalation in a controlled environment. While establishing clear and firm limits (Choice B) may be necessary in some situations, the immediate priority here is safety. Offering medication (Choice C) should not be the first response unless the situation escalates further and poses a risk to the client or others. Speaking with the client in a calm, non-threatening manner (Choice D) may not be effective when the client is in an agitated state and engaging in risky behavior.

5. A mental health worker is caring for a client with escalating aggressive behavior. Which action by the mental health worker warrants immediate intervention by the RN?

• A. Attempting to physically restrain the client.
• B. Remaining at a distance of 4 feet from the client.
• C. Telling the client to go to the quiet area of the unit.
• D. Using a loud voice to communicate with the client.

Correct answer: A

Rationale: Attempting to physically restrain the client without proper protocol and preparation can escalate the situation. This can lead to increased agitation and aggression in the client, potentially putting both the client and the mental health worker at risk. Remaining at a distance, directing the client to a quiet area, or using a loud voice are all strategies that can be used to de-escalate the situation and ensure safety without resorting to physical intervention. Therefore, the immediate intervention is needed when the mental health worker attempts to physically restrain the client. Option B, remaining at a distance, is a safe practice to ensure personal safety. Option C, directing the client to a quiet area, is a de-escalation technique to create a calmer environment. Option D, using a loud voice, may be necessary to establish boundaries and ensure the client can hear instructions clearly.

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