Nursing Elites

1. A client comes into the emergency room and asks to see a doctor. He is anxious, visibly upset, and keeps looking behind him to the waiting room. When the nurse asks his chief complaint, he says, 'My roommate is trying to kill me.' Which of the following is the most appropriate initial response of the nurse?

• A. Just wait here and I will notify security.
• B. I'm going to speak with the physician about getting some medication that may help you.
• C. Why is your roommate trying to kill you?
• D. Have you called the police to report this?

Correct answer: C

Rationale: Upon initial assessment of a client who appears anxious and upset, with claims that need further exploration, the nurse's initial response should be to gather more information about the situation. By asking 'Why is your roommate trying to kill you?' the nurse shows empathy while trying to understand the patient's perspective. This open-ended question allows the nurse to assess the situation comprehensively. Options A and D jump to conclusions or suggest actions without understanding the situation. Option B focuses solely on medication without addressing the underlying issue. It is crucial to assess the situation further before taking any action or providing treatment.

2. The nurse has just admitted a client with severe depression. From which focus should the nurse identify a priority nursing diagnosis?

• A. Nutrition
• B. Elimination
• C. Activity
• D. Safety

Correct answer: D

Rationale: In caring for a client with severe depression, ensuring safety is a top priority. Suicide prevention measures must be incorporated into the care plan as individuals with depression are at increased risk. While nutrition, elimination, and activity are important aspects of care, safety takes precedence due to the critical need to prevent harm or self-harm in depressed individuals.

3. A client is having difficulty applying for a job due to panic and anxiety. A nurse is helping by pretending to be the job supervisor while the client practices answering questions during an imaginary interview. This technique is an example of:

• A. Reinforcement
• B. Presenting reality
• C. Role playing
• D. Summarizing

Correct answer: C

Rationale: Role-playing is the correct answer. It involves practicing appropriate behaviors during imaginary scenarios that simulate real-life situations. In this scenario, the nurse is helping the client prepare for a job interview by acting as the job supervisor. Role-playing allows the client to practice and develop strategies to cope with anxiety and panic during the actual interview. Reinforcement (Choice A) involves providing consequences to strengthen a behavior. Presenting reality (Choice B) involves helping the client differentiate between real and unreal experiences. Summarizing (Choice D) involves condensing information. In this context, role-playing is the most appropriate technique to address the client's anxiety and panic related to job interviews.

4. The mental health nurse plans to discuss a client's depression with the health care provider in the emergency department. There are two clients sitting across from the emergency department desk. Which nursing action is best?

• A. Only refer to the client by gender
• B. Identify the client only by age
• C. Avoid using the client's name
• D. Discuss the client another time

Correct answer: D

Rationale: The best nursing action is to discuss the client another time to ensure confidentiality. It is important to maintain the privacy of the client's information, so discussing sensitive topics like depression in a public area where conversations can be overheard is not appropriate. While options A, B, and C may seem like ways to protect the client's identity, they do not guarantee confidentiality since details like gender or age can still lead to identification. Therefore, the nurse should prioritize privacy and confidentiality by finding a more suitable time and location to have a private discussion about the client's concerns.

5. A health care provider discusses with a client the need for an abdominoperineal resection and a colostomy. After the health care provider leaves the room, the client tells the nurse about being relieved that only minor surgery is necessary. Which psychological process explains this client's reaction?

• A. Reflection
• B. Regression
• C. Repudiation
• D. Reconciliation

Correct answer: C

Rationale: The client's reaction of believing that only minor surgery is necessary when faced with the need for an abdominoperineal resection and a colostomy is an example of repudiation. Repudiation involves a refusal to acknowledge anticipated loss as a defense mechanism against the overwhelming stress of illness. The client is psychologically denying the seriousness of the situation. The other choices are incorrect because: - Reflection (Choice A) does not apply since the client is not contemplating the issues of the situation. - Regression (Choice B) is not demonstrated as the client's behavior does not indicate reverting to an earlier stage of development. - Reconciliation (Choice D) is not applicable as the client has not made a realistic adjustment to the illness but rather is in denial of its severity.

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