Nursing Elites

1. During the admission assessment, a female client requests that her husband be allowed to stay in the room. While interviewing the client, the nurse notes a discrepancy between the client's verbal and nonverbal communication. What action should the nurse take?

• A. Pay close attention and document the nonverbal messages
• B. Ask the client's husband to interpret the discrepancy
• C. Ignore the nonverbal behavior and focus on the client's verbal messages
• D. Integrate the verbal and nonverbal messages and interpret them as one

Correct answer: A

Rationale: Noting both verbal and nonverbal cues is crucial to fully understand the client's condition and any potential underlying issues. Verbal communication may not always align with nonverbal cues, which can provide valuable insights into the client's emotional state and concerns. By paying close attention to and documenting the nonverbal messages, the nurse can gather a more comprehensive understanding of the client's situation. Asking the client's husband to interpret the discrepancy may not be appropriate as it could lead to misinterpretation or breach of confidentiality. Ignoring the nonverbal behavior could result in missing essential cues affecting the overall assessment. Integrating both verbal and nonverbal messages helps in forming a holistic view of the client's needs and concerns, enabling better care delivery.

2. A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The RN also determines that the client is homeless and is exhibiting suspiciousness. The client's plan of care should include what priority problem?

• A. Acute confusion.
• B. Ineffective community coping.
• C. Disturbed sensory perception.
• D. Self-care deficit.

Correct answer: A

Rationale: Acute confusion is the priority problem as it directly affects the client's ability to process information and make safe decisions. In this scenario, the client's disorientation, disorganization, and confusion indicate an immediate cognitive issue that requires attention to ensure her safety and stability. Choices B, C, and D are not the priority problems in this case. Ineffective community coping, disturbed sensory perception, and self-care deficit, while important, are secondary to the client's acute confusion, which poses an immediate risk to her well-being.

3. A client sought counseling after trying to rescue a neighbor involved in a house fire. Despite the client's efforts, the neighbor died. Which action does the nurse engage in with the client during the working phase of the nurse-client relationship?

• A. Exploring the client's ability to function
• B. Exploring the client's potential for self-harm
• C. Inquiring about the client's perception of appraisal of the neighbor's death
• D. Inquiring about and examining the client's feelings that may block adaptive coping

Correct answer: D

Rationale: During the working phase of the nurse-client relationship, it is crucial for the nurse to inquire about and examine the client's feelings that may hinder adaptive coping. This helps the client process the traumatic event, explore their emotional responses, and identify any barriers to moving forward effectively. Exploring the client's ability to function (Choice A) may be more relevant in the assessment phase, while exploring the client's potential for self-harm (Choice B) is important but may not be the primary focus at this stage. Inquiring about the client's perception of the neighbor's death (Choice C) is valuable, but addressing feelings blocking adaptive coping is essential for therapeutic progress.

4. A client diagnosed with undifferentiated schizophrenia is being discharged on aripiprazole (Abilify) 5 mg every night. When developing the teaching plan about the most common adverse effects, which of the following should the nurse include? Select one that does not apply.

• A. Headaches that will subside in a few weeks
• B. Transient mild anxiety
• C. Insomnia
• D. Torticollis

Correct answer: D

Rationale: The correct answer is D: Torticollis. Common side effects of aripiprazole include headaches, mild anxiety, and insomnia. These side effects are manageable during treatment. Torticollis is not a common adverse effect associated with aripiprazole and is more commonly seen with other medications or conditions. Therefore, the nurse should not include torticollis in the teaching plan about the most common adverse effects of aripiprazole.

5. A client is admitted to the psychiatric unit with a diagnosis of major depressive disorder. The LPN/LVN notes that the client has not bathed or dressed in clean clothes for several days. What is the most appropriate intervention for the nurse to implement?

• A. Encourage the client to take a shower.
• B. Assist the client with activities of daily living.
• C. Provide the client with clean clothes to change into.
• D. Explain the importance of personal hygiene to the client.

Correct answer: B

Rationale: The correct answer is to assist the client with activities of daily living. This intervention is the most appropriate as it directly addresses the client's immediate needs by providing assistance with personal hygiene and dressing. It promotes self-care and ensures the client's well-being. Encouraging the client to take a shower (Choice A) may not be effective if the client is unable to do so independently due to their condition. Providing clean clothes (Choice C) is important but does not address the client's need for assistance with personal care. Explaining the importance of personal hygiene (Choice D) may not be as effective as providing direct assistance in this situation.

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