Nursing Elites

1. A female client presents to the emergency center with confusion, emotional numbness, and expresses to the nurse a feeling of disbelief that she was raped. The nurse determines the client is in the acute phase of rape-trauma syndrome. What action should the nurse implement first?

• A. Secure samples of vaginal hair combings.
• B. Offer prophylactic antibiotic medication.
• C. Explain the rape protocol to the client.
• D. Implement crisis intervention counseling.

Correct answer: C

Rationale: In cases of rape-trauma syndrome, it is crucial to provide clear information about what to expect during the examination and treatment. This can help the client regain a sense of control and reduce anxiety. Explaining the rape protocol to the client should be the first action to implement. Option A is not the priority at this stage as the immediate focus is on addressing the client's emotional needs and providing support. Option B is not the first action unless medically indicated. Option D, crisis intervention counseling, is important but should come after providing essential information and support to the client.

2. A female client with obsessive compulsive personality disorder is admitted to the hospital for a cardiac catheterization. The afternoon before the procedure, the client begins to keep detailed notes of the nursing care she is receiving and reports her findings to the RN at bedtime. What action should the nurse implement?

• A. Explain to the client that her behavior invades the rights of the nursing staff.
• B. Ask the client to explain why she is keeping a detailed record of her nursing care.
• C. Teach the client strategies to control her obsessive compulsive behavior.
• D. Encourage the client to express her feelings regarding the upcoming procedure.

Correct answer: D

Rationale: Encouraging the client to express her feelings can help address underlying anxieties and may reduce the need for obsessive behaviors. Choice A is incorrect because it may come across as confrontational and could escalate the situation. Choice B is not the best initial action as it focuses on the behavior rather than the client's emotions. Choice C is premature without first addressing the client's emotional needs.

3. A male client is admitted to a mental health unit on Friday afternoon and is very upset on Sunday because he has not had the opportunity to talk with the healthcare provider. Which response is best for the nurse to provide this client?

• A. Let me call and leave a message for your healthcare provider.
• B. The healthcare provider should be here on Monday morning.
• C. How can I help answer your questions?
• D. What concerns do you have at this time?

Correct answer: A

Rationale: It is best for the nurse to call the healthcare provider (A) because clients have the right to information about their treatment. Suggesting that the healthcare provider will be available the following day (B) does not provide immediate reassurance to the client. While offering to help answer questions (C) and inquiring about concerns (D) are supportive approaches, contacting the healthcare provider is the most appropriate action to address the client's immediate need for communication with their healthcare provider.

4. An elderly female client with advanced dementia is admitted to the hospital with a fractured hip. The client repeatedly tells the staff, 'Take me home. I want my Mommy.' Which response is best for the nurse to provide?

• A. Orient the client to the time, place, and person.
• B. Tell the client that the nurse is there and will help her.
• C. Remind the client that her mother is no longer living.
• D. Explain the seriousness of her injury and need for hospitalization.

Correct answer: B

Rationale: Those with dementia often refer to home or parents when seeking security and comfort. The nurse should use the techniques of 'offering self' and 'talking to the feelings' to provide reassurance (B). Clients with advanced dementia have permanent physiological changes in the brain (plaques and tangles) that prevent them from comprehending and retaining new information, so choices A, C, and D are likely to be of little use to this client and do not address the emotional needs expressed by the client. Option B acknowledges the client's feelings, offers support, and provides reassurance, which can help comfort the client during this distressing time.

5. A client with generalized anxiety disorder (GAD) is prescribed alprazolam (Xanax). What is the most important teaching point for the nurse to include?

• A. Take this medication at the first sign of anxiety.
• B. Do not stop taking this medication abruptly.
• C. You may experience weight gain while taking this medication.
• D. This medication may cause vivid dreams.

Correct answer: B

Rationale: The most important teaching point for a client prescribed alprazolam is not to stop taking the medication abruptly. Abruptly stopping alprazolam, a benzodiazepine, can lead to withdrawal symptoms. It is crucial to taper off the medication under medical supervision to prevent adverse effects. Choice A is incorrect because taking the medication at the first sign of anxiety is not the key teaching point. Choice C is incorrect because weight gain is not a common side effect of alprazolam. Choice D is incorrect because vivid dreams are not a significant concern compared to the risks of abrupt discontinuation of the medication.

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