Nursing Elites

1. A female client on the psychiatric unit tells the nurse that she feels like ending her life because she can no longer deal with her depression. What is the nurse's priority intervention?

• A. Stay with the client and ensure her safety.
• B. Inform the client that she is safe in the hospital.
• C. Document the client's statements in her medical record.
• D. Encourage the client to join a group therapy session.

Correct answer: A

Rationale: The correct answer is to stay with the client and ensure her safety. Ensuring the client's safety is the top priority when a client expresses suicidal ideation. Staying with the client can help prevent self-harm while further assessment and interventions are arranged. Choice B is incorrect because simply informing the client that she is safe in the hospital does not address the immediate need for safety. Choice C is incorrect as while documentation is important, it is not the priority when a client's safety is at risk. Choice D is also incorrect as encouraging the client to join a group therapy session is not appropriate when the client is in crisis and expressing suicidal thoughts.

2. A client who has recently been diagnosed with schizophrenia tells the LPN/LVN, 'I hear voices telling me to hurt myself.' What is the most appropriate nursing action?

• A. Encourage the client to ignore the voices.
• B. Tell the client that the voices will go away with medication.
• C. Monitor the client for signs of self-harm.
• D. Refer the client for a psychiatric evaluation.

Correct answer: D

Rationale: The correct answer is to refer the client for a psychiatric evaluation. The client's statement indicating hearing voices telling them to hurt themselves is a serious concern and suggests a risk for self-harm. Referring the client for a psychiatric evaluation is crucial for further assessment and intervention by mental health professionals. Choice A is incorrect because ignoring the voices may not address the client's safety. Choice B is incorrect as it oversimplifies the situation and does not address the immediate risk. Choice C is not as comprehensive as referring for a psychiatric evaluation, which is necessary in this situation.

3. A male client with bipolar disorder has not slept or eaten in four days. He paces and becomes increasingly agitated and loud while the nurse talks to his spouse. What intervention is the best for the nurse to implement at this time?

• A. Move to a quiet area and provide peanut butter with crackers.
• B. Walk with the client to the cafeteria and star as he eats lunch.
• C. Request a full lunch tray from the dietary department.
• D. Encourage the spouse to eat lunch with the client.

Correct answer: A

Rationale: In this situation, the best intervention for the nurse to implement is to move the client to a quiet area and provide peanut butter with crackers. The client's behavior indicates increasing agitation and loudness, which could be exacerbated by a noisy environment. Providing a quiet space can help reduce stimuli and promote a sense of calm. Additionally, offering a small, manageable snack like peanut butter with crackers can address the client's immediate needs for sustenance without overwhelming him. Choices B, C, and D do not address the client's current agitation and lack of sleep or food effectively, making them less appropriate interventions in this scenario.

4. A homeless person who is in the manic phase of bipolar disorder is admitted to the mental health unit. Which laboratory finding obtained on admission is most important for the nurse to report to the healthcare provider?

• A. Decreased thyroid stimulating hormone level
• B. Elevated liver function profile
• C. Increased white blood cell count
• D. Decreased hematocrit and hemoglobin levels

Correct answer: A

Rationale: The correct answer is A: Decreased thyroid stimulating hormone level. Hyperthyroidism causes an increased level of serum thyroid hormones (T3 and T4), which inhibit the release of TSH. In this case, a decreased TSH level can indicate hyperthyroidism, which can present with manic behavior. Elevated liver function profile (B) is not directly related to the manic phase of bipolar disorder. Increased white blood cell count (C) typically indicates an infection or inflammation, not directly related to the manic phase. Decreased hematocrit and hemoglobin levels (D) may suggest anemia but are not as crucial in the context of a manic phase of bipolar disorder.

5. During an annual physical by the occupational nurse working in 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 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 you feel angry for no reason

Correct answer: C

Rationale: The correct responses are C and D. The nurse should acknowledge the employee's feelings of anger and suggest that expressing anger to strangers, like other drivers, could lead to unsafe situations. This response aims to prevent potential confrontations or harm. Choice A is incorrect as it doesn't address the specific situation of expressing anger while driving. Choice B is also incorrect as it is vague and doesn't provide practical advice to manage the anger effectively.

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