Nursing Elites

1. A client with a history of substance abuse is admitted to the hospital for treatment of a new illness. Which of the following is the most important to assess upon admission?

• A. History of recent drug use.
• B. Current employment status.
• C. Family history of mental illness.
• D. Recent weight changes.

Correct answer: A

Rationale: Assessing the history of recent drug use is crucial when admitting a client with a history of substance abuse. Understanding recent drug use helps in managing potential withdrawal symptoms, preventing drug interactions with the new treatment, and ensuring appropriate care. Assessing current employment status (choice B) is important for social and financial support but is not as crucial as assessing recent drug use in this scenario. Family history of mental illness (choice C) and recent weight changes (choice D) are also important aspects of assessment but are not as immediate and critical as evaluating recent drug use in a client with a history of substance abuse.

2. Which client statement suggests that the client is using a defense mechanism of projection to deal with anxiety related to admission to a psychiatric unit?

• A. At least I hit the wall instead of hitting the psychiatric aide.
• B. I am here because the police thought I was doing something wrong.
• C. I want to be here because I know it is the best psychiatric facility.
• D. Don’t believe everything my family tells you, I am not crazy.

Correct answer: A

Rationale: The correct answer is A because the client is projecting their own aggressive tendencies onto the psychiatric aide by suggesting hitting the wall instead of the aide. This statement reflects projection, a defense mechanism where one attributes their unacceptable feelings or impulses to others. Choice B reflects externalization rather than projection, Choice C reflects rationalization, and Choice D reflects denial.

3. What intervention is best for the nurse to implement for a male client with schizophrenia who is demonstrating echolalia, which is becoming annoying to other clients on the unit?

• A. Avoid acknowledging the behavior.
• B. Isolate the client from other clients.
• C. Administer a PRN sedative.
• D. Escort the client to his room.

Correct answer: D

Rationale: Echolalia, the constant repetition of what others are saying, can be disruptive to the therapeutic environment. The most appropriate intervention is to escort the client to his room. This action provides the client with a private space where he can engage in the behavior without disturbing other clients. Avoiding acknowledgment of the behavior (Choice A) may not address the issue and could lead to increased annoyance among other clients. Isolating the client (Choice B) may have negative psychological effects and should be avoided unless absolutely necessary for safety concerns. Administering a PRN sedative (Choice C) should be considered only as a last resort and if other de-escalation techniques have been unsuccessful.

4. A male client with bipolar disorder tells the nurse that he needs to 'make some deals so that he can improve his retirement savings.' Based on this information, which client outcome should the nurse include in the plan of care?

• A. Delay business decisions until his mania subsides.
• B. Identify the feelings associated with his behaviors.
• C. Seek legal counsel when making business decisions.
• D. Describe why he is feeling fearful about his finances.

Correct answer: A

Rationale: In individuals with bipolar disorder experiencing mania, impulsivity and poor judgment are common. Delaying business decisions until the mania subsides is crucial to prevent impulsive and potentially harmful financial choices. Choice B, identifying feelings associated with behaviors, may be important but does not directly address the immediate need to prevent risky financial decisions. Seeking legal counsel (Choice C) may be appropriate in some situations but is not the priority in managing acute mania. Describing why he feels fearful about finances (Choice D) is relevant for understanding emotions but does not address the immediate risk of impulsive financial actions during mania.

5. A female client requests that her husband be allowed to stay in the room during the admission assessment. While interviewing the client, the nurse notes a discrepancy between the client’s verbal and nonverbal communication. What action should the nurse take?

• A. Pay close attention and document the nonverbal messages.
• B. Ask the client’s husband to interpret the discrepancy.
• C. Ignore the nonverbal behavior and focus on the client’s verbal messages.
• D. Integrate the verbal and nonverbal messages and interpret them as one.

Correct answer: A

Rationale: When a nurse observes a discrepancy between a client's verbal and nonverbal communication, it is essential to pay close attention and document the nonverbal messages. Nonverbal cues, such as body language and facial expressions, can provide valuable insights into the client's emotional state, feelings, and concerns that may not be expressed verbally. By documenting these nonverbal messages, the nurse can gain a more comprehensive understanding of the client's communication and address any potential underlying issues. Asking the client's husband to interpret the discrepancy (Choice B) may not always provide an accurate understanding of the client's nonverbal cues. Ignoring the nonverbal behavior (Choice C) could lead to missing important cues affecting the client's care. Integrating verbal and nonverbal messages (Choice D) is important, but initially focusing on documenting and understanding the nonverbal cues can enhance the nurse's assessment and communication with the client.

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