Nursing Elites

1. A client with depression and a history of a recent suicide attempt is being discharged from the hospital. Which statement by the client indicates a need for further follow-up?

• A. “I will take my medication as prescribed.”
• B. “I have a plan to attend weekly therapy sessions.”
• C. “I feel that I am completely recovered now.”
• D. “I will avoid people who make me feel worse.”

Correct answer: C

Rationale: The correct answer is C. When a client with depression and a history of a recent suicide attempt states, “I feel that I am completely recovered now,” it indicates a need for further follow-up. This statement suggests a potential lack of insight into the ongoing nature of depression and may lead to discontinuation of necessary treatment and support. Choices A, B, and D demonstrate positive and proactive attitudes towards managing depression and suicidal ideation, indicating a willingness to engage in treatment, therapy, and self-care practices.

2. Carolina is surprised when her patient does not show for a regularly scheduled appointment. When contacted, the patient states, 'I don't need to come see you anymore. I have found a therapy app on my phone that I love.' How should Carolina respond to this news?

• A. That sounds exciting, would you be willing to visit and show me the app?
• B. At this time, there is no real evidence that the app can replace our therapy.
• C. I am not sure that is a good idea right now; we are so close to progress.
• D. Why would you think that is a better option than meeting with me?

Correct answer: A

Rationale: Carolina should respond with choice A as it shows interest and willingness to understand the patient's new approach. By asking the patient to show the app, Carolina demonstrates openness to exploring the patient's perspective and the technology they find helpful. Choice B is incorrect as it appears dismissive, failing to acknowledge the patient's autonomy in choosing an alternative therapy method. Choice C is also inappropriate as it undermines the patient's decision-making and progress achieved so far. Choice D comes off as confrontational and judgmental, which could lead to the patient feeling defensive and less likely to engage in a constructive conversation.

3. 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.

4. A female client, who is wearing dirty clothes and has a foul body odor, comes to the clinic reporting feeling scared because she is being stalked. What action is most important for the nurse to take?

• A. Assure the client that she will be seen by a healthcare provider today.
• B. Recommend that the client speaks with a social worker.
• C. Ask the client if she feels comfortable sharing why she is being stalked.
• D. Offer the client a safe place to relax before interviewing her.

Correct answer: D

Rationale: The most important action for the nurse to take in this scenario is to offer the client a safe place to relax before interviewing her. The client's disheveled appearance and foul body odor suggest she may be in distress or facing challenging circumstances. By providing her with a safe and comfortable environment to relax, the nurse can help alleviate some of her distress and establish trust. This approach is crucial as the client is already feeling scared due to being stalked, indicating underlying mental health concerns. Assuring the client that she will be seen by a healthcare provider today (choice A) may not address her immediate need for safety and comfort. Recommending she speaks with a social worker (choice B) may be beneficial later but does not address the immediate need for a safe space. Asking the client if she feels comfortable sharing why she is being stalked (choice C) is not appropriate as the priority is ensuring her safety and comfort first.

5. When developing a plan of care for a client admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing problem has the highest priority?

• A. Impaired comfort.
• B. Risk for injury.
• C. Ineffective breathing pattern.
• D. Ineffective coping.

Correct answer: C

Rationale: Ineffective breathing pattern is the highest priority nursing problem in this scenario because aspiration of a caustic material can lead to serious airway and respiratory issues. This poses an immediate threat to the client's life and requires urgent intervention to ensure adequate oxygenation and ventilation. The other options, such as Impaired comfort, Risk for injury, and Ineffective coping, are important but are secondary concerns compared to the critical nature of respiratory compromise in this situation.

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