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 with depression is prescribed an SSRI. The client asks, 'Why do I need to take this medication every day?' What is the best response by the nurse?

• A. This medication will help balance the chemicals in your brain.
• B. This medication needs to be taken regularly to be effective.
• C. This medication will start working immediately to improve your mood.
• D. You should take this medication only when you feel sad or depressed.

Correct answer: D

Rationale: Explaining that the medication may take several weeks to take full effect helps manage the client's expectations and encourages adherence to the prescribed treatment.

3. The nurse is leading a 'current events group' with chronic psychiatric clients. One group member states, 'Clara Barton was my nurse during my last hospitalization. She was a very mean nurse and wasn't nice to me.' Which response would be best for the nurse to make?

• A. 'Clara Barton was not your nurse.'
• B. 'What did she do to you that was so mean?'
• C. 'I didn't know that Clara Barton was a nurse.'
• D. 'Clara Barton started the American Red Cross.'

Correct answer: D

Rationale: (D) presents the reality of the situation in relation to American culture. The fact that Clara Barton was a nurse during the Civil War should be addressed on an individual basis. Since this is group therapy, the nurse would be illustrating the concept of universality. (A) is likely to promote defensiveness. (B and C) would support the delusion. Therefore, the most appropriate response is (D) as it provides factual information that can redirect the conversation in a constructive manner.

4. During initial assessment of the teenager, what information is most important for the nurse to obtain from the parents?

• A. If he has seemed depressed recently.
• B. If a drug overdose has ever occurred before.
• C. If he might have taken any other drugs.
• D. If he has a desire to quit taking drugs.

Correct answer: C

Rationale: The correct answer is C. It's crucial to determine if the teenager might have taken other substances besides the pain pills mentioned by the mother. This information is vital for effective treatment because knowing the full scope of substances involved helps in managing potential interactions, side effects, and the overall condition of the patient. Options A, B, and D are not as critical in the immediate assessment compared to knowing if the teenager has ingested any other drugs.

5. An LPN/LVN is caring for a suicidal client. The appropriate nursing intervention in dealing with this client is to:

• A. Demonstrate confidence in the client's ability to deal with stressors
• B. Provide hope and reassurance that the problems will resolve themselves
• C. Display an attitude of detachment, confrontation, and efficiency
• D. Provide authority, action, and participation

Correct answer: D

Rationale: When caring for a suicidal client, providing authority, taking action, and encouraging the client's participation in their care are essential. Choice A is incorrect as it may not be sufficient for the critical situation of a suicidal client. Choice B, while offering hope, may not address the immediate risk of harm. Choice C's attitude of detachment and confrontation can be counterproductive in establishing trust and rapport with the client. Therefore, the most appropriate intervention is to provide authority, take action to ensure safety, and involve the client in the care process.

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