Nursing Elites

1. A client with borderline personality disorder is admitted to the psychiatric unit. Which intervention should the nurse implement to promote the client's safety?

• A. Implement a no-harm contract with the client.
• B. Monitor the client closely for signs of self-harm.
• C. Encourage the client to participate in recreational activities.
• D. Encourage the client to maintain a structured daily routine.

Correct answer: A

Rationale: When a client with borderline personality disorder is admitted to a psychiatric unit, implementing a no-harm contract is a crucial intervention to promote the client's safety. A no-harm contract is a formal agreement between the client and the healthcare provider stating that the client commits to not harm themselves or others. This intervention helps in establishing boundaries and promoting safety by enhancing communication and accountability between the client and the healthcare team. Monitoring the client closely for signs of self-harm (Choice B) is important but does not directly address promoting safety through a formal agreement. Encouraging participation in recreational activities (Choice C) and maintaining a structured daily routine (Choice D) are beneficial interventions but may not directly address the immediate safety concerns of a client with borderline personality disorder.

2. A teenage boy is attracted to a female teacher. Without objective evidence, a school nurse overhears the boy state, 'I know she wants me.' This statement reflects which defense mechanism?

• A. Displacement
• B. Projection
• C. Rationalization
• D. Sublimation

Correct answer: B

Rationale: The correct answer is B: Projection. The nurse should determine that the client's statement reflects the defense mechanism of projection. Projection involves attributing one's unacceptable feelings or impulses to another person. By projecting these feelings onto someone else, the individual reduces their own anxiety. Displacement involves transferring feelings from one target to another, not attributing them to another person. Rationalization involves making excuses to justify behavior, not attributing feelings to others. Sublimation involves channeling unacceptable drives or impulses into more constructive and acceptable activities, not attributing feelings to another person.

3. Which of the following are therapeutic communication techniques that a healthcare provider can use when interacting with clients? Select one that does not apply.

• A. Using Noise
• B. Offering self
• C. Giving advice
• D. Providing reassurance

Correct answer: C

Rationale: Therapeutic communication techniques aim to promote a therapeutic relationship and client well-being. Using noise is a non-therapeutic technique that can hinder effective communication. Offering self, providing reassurance, and using silence are considered therapeutic. However, giving advice is often seen as non-therapeutic as it can diminish client autonomy and hinder problem-solving skills.

4. In a patient with schizophrenia, which of the following symptoms would indicate a poor prognosis?

• A. Auditory hallucinations
• B. Paranoia
• C. Flat affect
• D. Delusions of grandeur

Correct answer: C

Rationale: A flat affect, characterized by a lack of emotional expression, is often linked to a poorer prognosis in schizophrenia. It can hinder social interactions and affect the individual's ability to engage in therapy or express emotions, thereby impacting the overall treatment outcomes. Auditory hallucinations (Choice A) and delusions of grandeur (Choice D) are common symptoms in schizophrenia but may not always indicate a poor prognosis. Paranoia (Choice B) can also vary in its impact on prognosis depending on the individual and the severity of the symptom.

5. A client with schizophrenia is experiencing auditory hallucinations. Which intervention should the nurse implement first?

• A. Ask the client to describe the content of the hallucinations.
• B. Instruct the client to ignore the hallucinations.
• C. Administer prescribed antipsychotic medication.
• D. Engage the client in reality-based activities.

Correct answer: A

Rationale: The initial intervention for a client experiencing auditory hallucinations, especially in schizophrenia, is to assess the content of the hallucinations. By asking the client to describe the hallucinations, the nurse can determine if they are command hallucinations that might pose a risk. This assessment is crucial in guiding further appropriate interventions to ensure the client's safety and well-being. Instructing the client to ignore the hallucinations (Choice B) may not be effective, as the hallucinations are real to the client. Administering antipsychotic medication (Choice C) may be necessary but should come after assessing the situation. Engaging the client in reality-based activities (Choice D) is important but not the first priority when dealing with auditory hallucinations.

Similar Questions