Nursing Elites

1. A client tells a nurse, 'Don’t tell anyone, but I hid a sharp knife under my mattress to protect myself from my threatening roommate.' Which of the following actions should the nurse take?

• A. Keep the client’s communication confidential, but talk to the client daily using therapeutic communication to convince them to admit to hiding the knife
• B. Keep the client’s communication confidential, but watch the client and their roommate closely
• C. Tell the client that this must be reported to the health care team because it concerns the health and safety of the client and others
• D. Report the incident to the health care team but do not inform the client of the intention to do so

Correct answer: C

Rationale: In this scenario, the nurse must prioritize the safety of the client and others. The client's disclosure of hiding a sharp knife under the mattress poses a significant risk. It is crucial for the nurse to inform the health care team about this situation to ensure immediate intervention and prevent any harm. Confidentiality is important in nursing care, but in cases where there is a clear threat to safety, the duty to protect overrides the duty of confidentiality. Reporting the incident to the health care team is essential to address the safety concerns and provide appropriate support and intervention for the client. Choices A and B are incorrect because while confidentiality is important, the immediate safety concern outweighs keeping the client's communication confidential or simply monitoring the situation. Choice D is incorrect as it does not involve informing the client, which can impact the therapeutic relationship and trust between the nurse and the client.

2. A healthcare professional is assessing a patient with bipolar disorder. Which finding suggests the patient is experiencing a manic episode?

• A. Decreased need for sleep
• B. Feelings of worthlessness
• C. Increased need for sleep
• D. Avoidance of social interactions

Correct answer: A

Rationale: During a manic episode in patients with bipolar disorder, they often experience a decreased need for sleep. This symptom is characterized by feeling rested after only a few hours of sleep, or even feeling like they can go without sleep for extended periods without feeling tired. The increased energy levels and racing thoughts during a manic episode contribute to the decreased need for sleep.

3. When the caregiver of a child asks the nurse for reassurance about their child’s condition, which of the following responses should the nurse make?

• A. “I think your child is getting better. What have you noticed?”
• B. “I’m sure everything will be okay. It just takes time to heal.”
• C. “I’m not sure what’s wrong. Have you asked the doctor about your concerns?”
• D. “I understand you’re concerned. Let’s discuss what concerns you specifically.”

Correct answer: D

Rationale: When providing reassurance to a caregiver about their child’s condition, it's essential to acknowledge their concern and address it specifically. Response D demonstrates empathy and a willingness to discuss the caregiver's specific concerns, which can help in providing accurate information and support to them. Choices A and B provide general reassurance without addressing the caregiver's specific concerns, which may not alleviate their worries effectively. Choice C deflects the question back to the caregiver and suggests consulting the doctor without directly engaging with the caregiver's worries, which may not offer the needed support and reassurance.

4. A nurse is providing discharge teaching to a patient prescribed fluoxetine for panic disorder. Which statement should be included in the teaching?

• A. You should notice the effects of this medication within a few days.
• B. It's important to take this medication only when you feel anxious.
• C. It may take several weeks before you notice the full effects of this medication.
• D. You can stop taking this medication as soon as you feel better.

Correct answer: C

Rationale: The correct statement to include in the teaching is that it may take several weeks before the patient notices the full effects of fluoxetine. This is because fluoxetine, like other SSRIs, requires time to reach its full therapeutic effect. Choice A is incorrect as fluoxetine does not show its effects within a few days. Choice B is incorrect as fluoxetine should be taken regularly as prescribed, not only when feeling anxious. Choice D is incorrect as discontinuing fluoxetine abruptly can lead to withdrawal symptoms and a return of panic disorder symptoms.

5. What is the priority intervention for a patient admitted for an overdose of sedatives and diagnosed with dissociative identity disorder?

• A. Conducting a suicide assessment
• B. Arranging for placement in a group home
• C. Providing a low-stimulation environment
• D. Establishing trust and rapport

Correct answer: A

Rationale: Conducting a suicide assessment is the priority intervention for a patient admitted for an overdose of sedatives and diagnosed with dissociative identity disorder. In this scenario, the immediate concern is to assess the risk of harm to the patient's life. It is crucial to determine if the overdose was intentional and if the patient has suicidal ideation or intent. Arranging for placement in a group home (choice B) may be necessary at a later stage depending on the patient's needs, but it is not the priority in this urgent situation. Providing a low-stimulation environment (choice C) and establishing trust and rapport (choice D) are important aspects of care but addressing the immediate risk of suicide takes precedence in this case.

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