Nursing Elites

1. Which response would the nurse make to a client who says, 'The voices say I'll be safe only if I stay in this room, wear these clothes, and avoid stepping on the cracks between the floor tiles'?

• A. Ask whether the voices are male or female and how many there are.
• B. Reassure the client by stating, 'I understand that these voices are real to you, but I want you to know that I don't hear them.'
• C. Offer false reassurance by saying, 'Don't worry"?I've locked the door to your room and won't let anyone in.'
• D. Encourage the client to leave the room and keep busy to distract from the voices.

Correct answer: B

Rationale: The response, 'I understand that these voices are real to you, but I want you to know that I don't hear them,' demonstrates empathy and validation of the client's experience while also gently bringing in the nurse's reality. This response acknowledges the client's feelings without reinforcing the hallucinations. Asking about the characteristics of the voices (Choice A) can inadvertently validate the hallucinations. Offering false reassurance (Choice B) may not be helpful as it does not address the client's distress. Encouraging the client to leave the room and keep busy (Choice D) is nontherapeutic as it disregards the client's experience and may increase anxiety.

2. What should be the initial action for a client admitted to an alcohol rehabilitation center who has a strong odor of alcohol on their breath on the fourth day after admission?

• A. Ask where the client obtained the alcohol.
• B. Locate the alcoholic substance.
• C. Convey empathy and support to the client.
• D. Document the client's drinking behavior.

Correct answer: B

Rationale: The initial action should be to locate the alcoholic substance. The nurse needs to find and remove the substance to prevent the client or others from consuming more alcohol. Asking where the client obtained the alcohol is not the priority; the focus is on ensuring the client's safety. Conveying empathy and support is essential but should not be the first action in this scenario. Documenting the client's drinking behavior can be done after ensuring immediate safety measures are in place.

3. The emergency room nurse admits a child who experienced a seizure at school. The father comments that this is the first occurrence and denies any family history of epilepsy. What is the best response by the nurse?

• A. Do not worry. Epilepsy can be treated with medications.
• B. The seizure may or may not mean your child has epilepsy.
• C. Since this was the first convulsion, it may not happen again.
• D. Long-term treatment will prevent future seizures.

Correct answer: B

Rationale: The correct response is, 'The seizure may or may not mean your child has epilepsy.' There are various potential causes for a childhood seizure, such as fever, central nervous system conditions, trauma, metabolic alterations, and idiopathic reasons. It's essential not to jump to conclusions about epilepsy based on one seizure. Options A, C, and D provide premature or inaccurate information. Option A may give false reassurance without proper evaluation, option C assumes one seizure guarantees no recurrence, and option D oversimplifies treatment outcomes.

4. The nurse transcribes the postoperative prescriptions for a client who returns to the unit following surgery and notes that an antihypertensive medication that was prescribed preoperatively is not listed. Which action should the nurse take?

• A. Consult with the pharmacist about the need to continue the medication.
• B. Administer the antihypertensive medication as prescribed preoperatively.
• C. Withhold the medication until the client is fully alert and vital signs are stable.
• D. Contact the health care provider to renew the prescription for the medication.

Correct answer: D

Rationale: In this scenario, the nurse has noted that an antihypertensive medication prescribed preoperatively is missing from the postoperative prescriptions. It is essential to renew preoperative medications postoperatively. Therefore, the correct action for the nurse to take is to contact the health care provider to renew the prescription for the antihypertensive medication. Consulting with the pharmacist about the need to continue the medication is not appropriate in this situation as pharmacists do not prescribe or renew medications. Administering the antihypertensive medication as prescribed preoperatively without a current prescription poses a risk to the client's safety. Withholding the medication until the client is fully alert and vital signs are stable does not address the issue of the missing prescription and delays the client's necessary treatment.

5. Which response would the nurse make when a client moans softly, 'Oh no, I'm next. They couldn't protect him, and they can't protect me,' after learning a recently discharged client committed suicide?

• A. ''The other person was a lot sicker than you are.''
• B. 'You seem to be afraid that you'll hurt yourself.''
• C. 'That was different. He was at home, but you're here.''
• D. 'There's no need to worry. You have a better support system.''

Correct answer: B

Rationale: The nurse would make the statement, 'You seem to be afraid that you'll hurt yourself.' This response acknowledges the client's emotional distress and opens up the opportunity for the client to discuss their feelings, showing empathy and understanding. Choice A, 'The other person was a lot sicker than you are,' dismisses the client's emotions and fails to address the underlying fear of self-harm. Choice C, 'That was different. He was at home, but you're here,' invalidates the client's concerns and does not encourage further discussion. Choice D, 'There's no need to worry. You have a better support system,' offers false reassurance and does not address the client's expressed fear, missing an opportunity for therapeutic communication.

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