Nursing Elites

1. A client, who is on a 30-day commitment to a drug rehabilitation unit, asks the nurse if he can go for a walk on the grounds of the treatment center. When he is told that his privileges do not include walking on the grounds, the client becomes verbally abusive. Which approach will the nurse take?

• A. Call a staff member to escort the client to his room.
• B. Tell the client to talk to his healthcare provider about his privileges.
• C. Remind the client of the unit rules.
• D. Ignore the client's inappropriate behavior.

Correct answer: C

Rationale: (C) is the correct approach in this situation as it reinforces unit rules, setting clear boundaries and expectations. By reminding the client of the unit rules, the nurse is helping to maintain a safe and structured environment within the drug rehabilitation unit. (A) is unnecessary since the client's behavior does not warrant immediate physical intervention. (B) is not ideal because the client's privileges have already been explained, and suggesting he speak to his healthcare provider may not address the immediate issue. (D) is not appropriate as addressing inappropriate behavior is essential in a therapeutic setting.

2. A client with schizophrenia is experiencing auditory hallucinations. What is the most appropriate nursing intervention?

• A. Encourage the client to ignore the voices.
• B. Ask the client what the voices are saying.
• C. Distract the client with a new activity.
• D. Tell the client that the voices are not real.

Correct answer: B

Rationale: Asking the client what the voices are saying is the most appropriate intervention as it helps the nurse assess the content of the hallucinations and the potential risk they may pose. Encouraging the client to ignore the voices (Choice A) may not address the underlying issue or provide valuable information for the nurse. Distracting the client with a new activity (Choice C) may temporarily divert attention but does not address the hallucinations. Telling the client that the voices are not real (Choice D) may invalidate the client's experience and can lead to distrust in the therapeutic relationship.

3. The community health nurse talks to a male client who has bipolar disorder. The client explains that he sleeps 4 to 5 hours a night and is working with his partner to start two new businesses and build an empire. The client stopped taking his medications several days ago. What nursing problem has the highest priority?

• A. Excessive work activity.
• B. Decreased need for sleep.
• C. Medication management.
• D. Inflated self-esteem.

Correct answer: D

Rationale: The priority is to manage the client's medication adherence to prevent escalation of manic behavior. Inflated self-esteem is the highest priority as it indicates the client's potential for harmful behaviors due to lack of medication compliance. While excessive work activity and decreased need for sleep are characteristics of mania, they are not as immediately concerning as the risk of harm related to inflated self-esteem.

4. The RN is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. Which strategies should be included in the safety plan? (select one that does not apply)

• A. Purchase a gun to use for protection.
• B. Keep quiet and calm.
• C. Take a self-defense course that retaliates against the abuser with injury.
• D. Have a bag ready that has extra clothes for self and children.

Correct answer: C

Rationale: Taking a self-defense course that retaliates against the abuser with injury can escalate the level of violence and is not recommended in a safety plan for a victim of intimate partner violence. The correct strategies include establishing a code, having a bag ready, and planning an escape route, which enhance safety without increasing the risk of harm.

5. A female client with schizophrenia is experiencing auditory hallucinations. What is the most therapeutic response by the nurse?

• A. I don't hear any voices. They must be in your head.
• B. What are the voices telling you to do?
• C. You need to ignore the voices and focus on reality.
• D. I know the voices are real to you, but I don't hear them.

Correct answer: D

Rationale: Acknowledging the client's experience while gently presenting reality can help build trust and provide reassurance without reinforcing the hallucination.

Similar Questions