Nursing Elites

1. A female client on a psychiatric unit is sweating profusely while vigorously doing push-ups and then running the length of the corridor several times before crashing into furniture in the sitting room. Picking herself up, she begins to verbally attack other clients. What intervention is most appropriate for the RN to use to manage the client’s behavior?

• A. Assist the client to a safe area to avoid injury.
• B. Establish clear and firm limits with the client.
• C. Offer medication to help calm the client down.
• D. Speak with the client in a calm, non-threatening manner.

Correct answer: A

Rationale: Assisting the client to a safe area is the most appropriate intervention in this scenario. This action helps prevent injury to the client and others while allowing for de-escalation in a controlled environment. While establishing clear and firm limits (Choice B) may be necessary in some situations, the immediate priority here is safety. Offering medication (Choice C) should not be the first response unless the situation escalates further and poses a risk to the client or others. Speaking with the client in a calm, non-threatening manner (Choice D) may not be effective when the client is in an agitated state and engaging in risky behavior.

2. A client on the mental health unit is becoming more agitated, shouting at the staff, and pacing in the hallway. When a PRN medication is offered, the client refuses the medication and defiantly sits on the floor in the middle of the unit hallway. What nursing intervention should the nurse implement first?

• A. Transport the client to the seclusion room.
• B. Quietly approach the client with additional staff members.
• C. Take other clients in the area to the client lounge.
• D. Administer medication to chemically restrain the client.

Correct answer: B

Rationale: In situations where a client is agitated and refusing medication, a non-confrontational approach with additional staff can help de-escalate the situation and address the client's behavior safely. Transporting the client to the seclusion room (Choice A) should not be the initial intervention unless the client poses an immediate risk of harm to themselves or others. Taking other clients to the client lounge (Choice C) does not directly address the agitated client's behavior. Administering medication to chemically restrain the client (Choice D) should only be considered after other de-escalation attempts have been made and if there is a significant safety concern.

3. During an annual physical at a corporate clinic, a male employee tells the nurse that his high-stress job is causing trouble in his personal life. He further explains that he often gets so angry while driving to and from work that he has considered “getting even” with other drivers. How should the nurse respond?

• A. “Anger is contagious and could result in a major confrontation.”
• B. “Try not to let your anger cause you to act impulsively.”
• C. “Expressing your anger to a stranger could result in an unsafe situation.”
• D. “It sounds as if there are many situations that make you feel angry.”

Correct answer: B

Rationale: The correct response is to encourage the client to manage their anger and avoid impulsive actions, as stated in choice B. This approach helps the individual recognize the potential consequences of acting on their anger impulsively. Choice A is not the best response because it focuses on the contagious nature of anger rather than addressing the individual's behavior. Choice C is incorrect as it only highlights the potential dangers of expressing anger to a stranger without providing guidance on managing the underlying issue. Choice D acknowledges the client's feelings but does not offer practical advice on how to address the anger and potential impulsive actions.

4. A healthcare provider is evaluating a client's response to a new antianxiety medication. Which client statement indicates a positive response to the medication?

• A. “I feel more relaxed and less anxious.”
• B. “I am sleeping less and feel more energetic.”
• C. “I have not noticed any changes in my anxiety levels.”
• D. “I have more difficulty concentrating than before.”

Correct answer: A

Rationale: The correct answer is A: “I feel more relaxed and less anxious.” A positive response to antianxiety medication is characterized by reduced anxiety and increased relaxation. Choice B, which mentions sleeping less and feeling more energetic, suggests potential side effects rather than a positive response to the medication. Choice C indicates no change in anxiety levels, which is not indicative of a positive response. Choice D, mentioning difficulty concentrating, is also a sign of a negative response to antianxiety medication as it may suggest cognitive impairment.

5. A female client engages in repeated checks of door and window locks, a behavior that prevents her from arriving on time and interferes with her ability to function effectively. What action should the nurse take?

• A. Ask the client why she checks the locks.
• B. Discuss checking the time frequently.
• C. Determine the type and size of the locks.
• D. Plan a list of activities to be carried out daily.

Correct answer: D

Rationale: Planning a list of daily activities can help the client manage her time better and reduce the impact of her compulsive behaviors. This structured approach can assist the client in organizing her day, potentially reducing the need for excessive lock checking. Option A is incorrect because simply asking why the client checks the locks may not address the underlying issue effectively. Option B is not relevant to the compulsive behavior of checking locks and does not offer a practical solution. Option C does not directly address the client's compulsive behavior but focuses on the physical attributes of the locks, which is not the primary concern in this scenario.

Similar Questions