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. Which action by a client who requires an above-the-knee amputation for peripheral arterial disease best indicates emotional readiness for the surgery?

• A. Explains the goals of the procedure
• B. Displays few signs of anticipatory grief
• C. Participates in learning perioperative care
• D. Verbalizes acceptance of permanent dependency needs

Correct answer: C

Rationale: Participating actively in learning self-care demonstrates emotional acceptance of the need for surgery and readiness for planning post-surgery. Explaining the goals of the procedure may reflect intellectual readiness but not necessarily emotional readiness. A client who shows few signs of anticipatory grief may be suppressing emotions or in denial, which can hinder the emotional readiness. Verbalizing acceptance of permanent dependency needs suggests the client may require further education and emotional support, as it may not reflect a healthy emotional readiness for the surgery.

3. Which response would the nurse make at lunchtime to a client who is sitting alone with the head slightly tilted as if listening to something?

• A. "I know you're busy, but it's lunchtime."
• B. "Are the voices bothering you again?"
• C. "Get going; you don't want to miss lunchtime."
• D. "It's lunchtime; I'll walk with you to the dining room."

Correct answer: D

Rationale: The statement, "It's lunchtime; I'll walk with you to the dining room," demonstrates setting limits and providing support. Hallucinations can be frightening, and the nurse's presence offers support and reality without focusing on the hallucination directly. Choice A, "I know you're busy, but it's lunchtime," does not recognize the client's need for support and direction. Choice B, "Are the voices bothering you again?", makes a judgment without sufficient evidence and overly focuses on the hallucination, failing to address the client's need for support and direction. Choice C, "Get going; you don't want to miss lunchtime," does not acknowledge the client's need for reality, support, and direction, and may come across as threatening.

4. Which implemented strategies would not be effective in preventing post-traumatic stress in the nursing staff?

• A. Providing breaks to the staff whenever needed
• B. Encouraging the staff to work for more than 12 hours per day
• C. Encouraging the staff to encourage and support their coworkers
• D. Asking the staff and managers to talk about their feelings with each other

Correct answer: B

Rationale: To prevent post-traumatic stress in the nursing staff, it is crucial to avoid overworking them. Encouraging staff to work for more than 12 hours per day can lead to burnout and increased stress levels, thus exacerbating post-traumatic stress. Providing breaks whenever needed is essential to ensure rest and rejuvenation during demanding shifts. Encouraging staff to support and uplift their coworkers can create a positive work environment, fostering resilience against stress. Additionally, promoting open communication by asking staff and managers to discuss their feelings can facilitate emotional processing and mutual support, ultimately reducing the risk of post-traumatic stress.

5. Which communication technique is a part of therapeutic communication?

• A. Asking for explanations
• B. Showing sympathy to the client
• C. Asking personal questions of the client
• D. Providing relevant information to the client

Correct answer: D

Rationale: The correct answer is providing relevant information to the client. In therapeutic communication, it is essential to provide clients with all pertinent information to help them understand their health status and what to expect. This empowers clients and promotes trust in the nurse-client relationship. Asking for explanations, showing sympathy, and asking personal questions are examples of nontherapeutic communication techniques. Asking personal questions can intrude on the client's privacy and may not be relevant to their care. Showing sympathy, while well-intentioned, may come across as pity rather than true empathy. Asking for explanations can sometimes put clients on the defensive rather than fostering a collaborative dialogue.

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