Nursing Elites

1. A client with schizophrenia is experiencing delusions. Which intervention should the nurse implement to address this symptom?

• A. Encourage the client to ignore the delusions.
• B. Provide reality-based feedback to the client.
• C. Distract the client from the delusions.
• D. Encourage the client to discuss the delusions.

Correct answer: B

Rationale: When a client with schizophrenia is experiencing delusions, providing reality-based feedback is considered an effective intervention to address this symptom. This approach helps the client differentiate between what is real and what is not real, assisting them in managing their delusions and promoting their overall well-being. Choice A is incorrect because ignoring the delusions does not help the client in distinguishing reality from delusions. Choice C is incorrect as distraction may only provide temporary relief but does not address the underlying issue. Choice D is incorrect because encouraging the client to discuss the delusions may reinforce or intensify them rather than help in managing them effectively.

2. Which of the following interventions is most appropriate for a client experiencing severe anxiety?

• A. Encourage the client to talk about their feelings.
• B. Provide a quiet and calm environment.
• C. Encourage the client to exercise vigorously.
• D. Encourage the client to participate in group activities.

Correct answer: B

Rationale: In cases of severe anxiety, creating a quiet and calm environment is crucial as it can help reduce stimulation and promote relaxation. This environment can provide a sense of safety and security, which are essential for individuals experiencing heightened anxiety levels. Encouraging the client to talk about their feelings may not be suitable during severe anxiety as it can further escalate distress by focusing on the source of anxiety. Vigorous exercise and group activities may not be appropriate initially, as they can increase arousal levels rather than promoting a sense of calm needed to manage severe anxiety.

3. James is a 42-year-old patient with schizophrenia. He approaches you as you arrive for the day shift and anxiously reports, 'Last night, demons came to my room and tried to rape me.' Which response would be most therapeutic?

• A. There are no such things as demons. What you saw were hallucinations.
• B. It is not possible for anyone to enter your room at night. You are safe here.
• C. You seem very upset. Please tell me more about what you experienced last night.
• D. That must have been very frightening, but we'll check on you at night and you'll be safe.

Correct answer: C

Rationale: Response C is the most therapeutic as it shows empathy and encourages the patient to express their feelings and share more about their experience. By actively listening and inviting the patient to talk, the nurse creates a supportive environment that can help the patient feel heard and understood, which is essential in building trust and rapport in therapeutic communication with individuals experiencing schizophrenia.

4. A client with bipolar disorder is experiencing a depressive episode. Which of the following interventions should the nurse not implement?

• A. Agree with the client's delusions to avoid confrontation.
• B. Monitor for signs of suicidal ideation
• C. Promote a regular sleep schedule
• D. Discourage the expression of negative feelings

Correct answer: A

Rationale: During a depressive episode in bipolar disorder, it is crucial not to agree with the client's delusions to avoid reinforcing false beliefs. Monitoring for signs of suicidal ideation is essential for safety. Promoting a regular sleep schedule can help stabilize mood. Discouraging the expression of negative feelings is not recommended as it is important to allow clients to express their emotions and feel heard.

5. A client has been diagnosed with generalized anxiety disorder and expresses worrying about their job, family, and health, feeling a loss of control. What should the nurse do first?

• A. Administer a prescribed antianxiety medication.
• B. Encourage the client to attend a support group.
• C. Identify triggers of the client's anxiety.
• D. Teach the client deep breathing techniques.

Correct answer: D

Rationale: The initial step for the nurse is to teach the client deep breathing techniques to aid in managing anxiety symptoms. Deep breathing exercises can help the client relax, reduce anxiety levels, and regain a sense of control. This intervention is non-invasive, empowering the client to develop a coping strategy for immediate use when feeling overwhelmed by anxiety. Administering medication (Choice A) should not be the first action unless the client is in severe distress. Encouraging attendance at a support group (Choice B) and identifying triggers of anxiety (Choice C) are important but teaching coping strategies like deep breathing comes first to help the client feel more in control of managing their anxiety.

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