Nursing Elites

1. A client with schizophrenia explains that she has 20 children and then very seriously points to the nurse and explains that she is one of them. What is the most therapeutic response for the nurse to provide?

• A. Let’s go ask another nurse if this is true.
• B. My name tag shows that I am a nurse here.
• C. I cannot possibly be one of your children.
• D. I know that you don’t have 20 children.

Correct answer: B

Rationale: Option B, 'My name tag shows that I am a nurse here,' is the most appropriate response as it provides clear and factual information to help the client differentiate between reality and delusion. By pointing out a concrete piece of evidence, the nurse can gently guide the client back to reality without directly challenging or contradicting their belief. Option A, 'Let’s go ask another nurse if this is true,' delays addressing the issue and doesn't provide immediate clarification. Option C, 'I cannot possibly be one of your children,' directly contradicts the client's statement and may increase distress. Option D, 'I know that you don’t have 20 children,' does not address the client's belief and can be perceived as dismissive.

2. The healthcare provider documents the mental status of a female client who has been hospitalized for several days by court order. The client states, “I don’t need to be here” and tells the healthcare provider that she believes that the television talks to her. The healthcare provider should document these assessment findings in which section of the mental status exam?

• A. Level of concentration
• B. Insight and judgment
• C. Remote memory
• D. Mood and affect

Correct answer: B

Rationale: Insight and judgment should be documented as these findings assess the client’s awareness of their need for treatment and understanding of their condition. In this scenario, the client’s statement of not needing to be hospitalized and belief that the television talks to her reflect her insight into her situation and judgment regarding reality. The other options are incorrect: Level of concentration refers to the ability to focus and maintain attention; Remote memory evaluates the recall of past events and information; Mood and affect assess emotional state and expression, which are not directly reflected in the client's statements about her need for hospitalization and belief about the television.

3. During an admission assessment and interview, which channels of information communication should the healthcare professional be monitoring? Select all that apply.

• A. Auditory
• B. Visual
• C. Written
• D. Tactile

Correct answer: A

Rationale: During an admission assessment and interview, healthcare professionals should monitor auditory, visual, and non-verbal cues. Auditory communication involves listening to the patient's spoken words, tone of voice, and any other sounds they make. Visual communication includes observing the patient's facial expressions, body language, and gestures. Written communication, such as forms or notes, may also provide valuable information. Tactile communication pertains to touch, which is not typically utilized during an admission interview setting. While all channels of communication are important, in this context, auditory cues are particularly crucial for gathering verbal information during the assessment process, making choice A the correct answer. Visual cues and written information are also significant but may not be as critical as auditory cues during an interview. Tactile communication is generally not a primary channel used during a standard admission assessment and interview, hence it is not a key focus in this scenario.

4. The nurse is developing unit policies that will include nursing guidelines for maintaining a therapeutic milieu. Which interventions should be included when providing a therapeutic milieu in an inpatient setting?

• A. Opportunities to contribute to one's treatment plan.
• B. One-on-one dialogue sessions with the therapist.
• C. Regularly scheduled unit activities for peer interaction.
• D. Home visits to reintegrate into the family.

Correct answer: C

Rationale: The nurse is responsible for maintaining a therapeutic milieu in an inpatient setting, which involves creating a secure and structured environment that promotes client safety and offers opportunities for clients to learn healthy coping skills. Regularly scheduled unit activities for peer interaction help foster socialization, support, and a sense of community among clients. Choices A and B are valuable interventions in mental health care but do not directly relate to creating a therapeutic milieu in an inpatient setting. Choice D, home visits, would typically occur post-discharge and focus on community reintegration, rather than maintaining a therapeutic milieu within the inpatient setting.

5. A client with obsessive-compulsive disorder (OCD) is receiving a new prescription for fluoxetine (Prozac). Which statement by the client indicates an understanding of this medication?

• A. “I should begin feeling less anxious within a few weeks.”
• B. “The drug will help me control my compulsive behaviors.”
• C. “I will need to have a weekly blood test to check my liver function.”
• D. “I should avoid foods that contain tyramine while taking this medication.”

Correct answer: B

Rationale: The correct answer is B. Fluoxetine, an SSRI, can help manage symptoms of OCD by assisting in controlling compulsive behaviors rather than directly reducing anxiety. The improvement in symptoms usually occurs over a few weeks. Choice A is incorrect as it provides a timeframe for anxiety improvement, which is not the primary goal of fluoxetine in OCD treatment. Choice C is incorrect as routine blood tests are not typically required with fluoxetine. Choice D is incorrect as avoiding tyramine-containing foods is more relevant for MAOIs, not SSRIs like fluoxetine.

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