Nursing Elites

1. A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. What action should the nurse implement?

• A. Attempt to ask the client simple questions.
• B. Postpone the client interview until the next day.
• C. Ask another nurse to talk with the client.
• D. Document the client's paranoid behavior.

Correct answer: A

Rationale: When a client is guarded, suspicious, and resistant to talking, it is important for the nurse to attempt to ask the client simple questions. Simple questions can help build rapport, establish trust, and create a non-threatening environment. This approach may ease the client into more detailed discussions while reducing feelings of suspicion. Postponing the interview may increase the client's anxiety and distrust, while asking another nurse to talk with the client may disrupt continuity of care and the establishment of a therapeutic relationship. Documenting the client's behavior is important for the client's medical record, but it should not be the first action taken in this situation.

2. A female client presents to the emergency center with confusion, emotional numbness, and expresses to the nurse a feeling of disbelief that she was raped. The nurse determines the client is in the acute phase of rape-trauma syndrome. What action should the nurse implement first?

• A. Secure samples of vaginal hair combings.
• B. Offer prophylactic antibiotic medication.
• C. Explain the rape protocol to the client.
• D. Implement crisis intervention counseling.

Correct answer: C

Rationale: In cases of rape-trauma syndrome, it is crucial to provide clear information about what to expect during the examination and treatment. This can help the client regain a sense of control and reduce anxiety. Explaining the rape protocol to the client should be the first action to implement. Option A is not the priority at this stage as the immediate focus is on addressing the client's emotional needs and providing support. Option B is not the first action unless medically indicated. Option D, crisis intervention counseling, is important but should come after providing essential information and support to the client.

3. Which statement about contemporary mental health nursing practice is accurate?

• A. There is one approved theoretical framework for psychiatric nursing practice.
• B. Psychiatric nursing has yet to be recognized as a core mental health discipline.
• C. Contemporary practice of psychiatric nursing is primarily focused on inpatient care.
• D. The psychiatric nursing client may be an individual, family, group, organization, or community.

Correct answer: D

Rationale: The accurate statement about contemporary mental health nursing practice is that the psychiatric nursing client may be an individual, family, group, organization, or community. Mental health nursing extends beyond individual care to address the impact of psychiatric stressors on families, groups, and entire communities. Choices A, B, and C are incorrect: A is false as there are various theoretical frameworks used in psychiatric nursing, B is inaccurate as psychiatric nursing is a core discipline in mental health, and C is wrong as contemporary psychiatric nursing involves various settings beyond just inpatient care.

4. An LPN/LVN is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented that the client is experiencing anxiety as a result of a situational crisis. The nurse determines that this type of crisis is caused by:

• A. Witnessing a murder
• B. The death of a loved one
• C. A fire that destroyed the client's home
• D. A recent rape episode experienced by the client

Correct answer: B

Rationale: The correct answer is B: 'The death of a loved one.' A situational crisis, like the death of a loved one, can lead to anxiety due to a significant change or loss in the person's life. Choices A, C, and D involve traumatic events, but a situational crisis typically refers to life events that disrupt an individual's normal pattern of living, such as the death of a loved one.

5. A 19-year-old female client with a diagnosis of anorexia nervosa wants to help serve dinner trays to other clients on a psychiatric unit. What action should the nurse take?

• A. Encourage the client's self-motivation by asking her to assist with other activities.
• B. Provide an alternative suggestion for the client to participate in the unit's activities.
• C. Allow the client to serve dinner trays to other clients but monitor closely for any signs of distress.
• D. Explain to the client that she needs to focus on her own recovery and cannot participate in serving dinner trays.

Correct answer: B

Rationale: Clients with anorexia should not be allowed to plan or prepare food for unit activities, as this can reinforce their perception of self-control. Allowing the client to serve dinner trays (C) may trigger distress or unhealthy behaviors. Therefore, it is best to provide an alternative suggestion for the client to participate in the unit's activities (B). Encouraging the client to assist with other activities (A) may inadvertently reinforce negative behaviors related to food. Explaining to the client that she cannot participate in serving dinner trays (D) without offering an alternative does not address the client's desire to help and may lead to feelings of rejection.

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