Nursing Elites

1. During the admission assessment, a female client requests that her husband be allowed to stay in the room. When the RN notes a discrepancy between the client’s verbal and nonverbal communication, what action should the RN take?

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

Correct answer: A

Rationale: During a client assessment, noting and documenting nonverbal messages is important as it captures the full context of the client’s communication. Nonverbal cues can often reveal underlying emotions or issues that may not be expressed verbally. Asking the client’s husband to interpret the discrepancy (Choice B) may not be appropriate as it could potentially breach the client's privacy and trust. Ignoring nonverbal behavior (Choice C) can result in missing important cues that could impact the care provided. Integrating verbal and nonverbal messages (Choice D) is beneficial, but the initial step should be to pay close attention and document the nonverbal messages to fully understand the client's communication.

2. 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.

3. A client with major depressive disorder is prescribed lithium carbonate. Which finding should the RN report to the healthcare provider?

• A. Serum lithium level of 0.8 mEq/L
• B. Blood urea nitrogen (BUN) level of 16 mg/dL
• C. Serum sodium level of 138 mEq/L
• D. Urine output of 800 mL in 24 hours

Correct answer: B

Rationale: The correct answer is B. Elevated BUN levels may indicate renal impairment, which is crucial to report for clients on lithium due to its potential kidney effects. Option A, a serum lithium level of 0.8 mEq/L, is within the therapeutic range for lithium and does not require immediate reporting. Option C, a serum sodium level of 138 mEq/L, is within the normal range and not directly related to lithium therapy. Option D, urine output of 800 mL in 24 hours, may indicate a need for further assessment but is not the most critical finding to report compared to potential renal impairment indicated by an elevated BUN level.

4. A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit’s day room. What action should the nurse implement first?

• A. Administer a PRN sedative.
• B. Sit in the chair next to the client.
• C. Escort the client to his room.
• D. Listen to what the client is saying.

Correct answer: D

Rationale: When dealing with a client experiencing auditory hallucinations, it is crucial for the nurse to first listen to what the client is saying. Auditory hallucinations may hold significance to the client, and by actively listening, the nurse can gather information about the content and context of the hallucinations. This information helps the nurse assess the client's current state, emotional responses, and the potential triggers for the behavior. Administering a PRN sedative (Choice A) should not be the initial action as it may suppress important information and feelings the client is trying to communicate. Sitting next to the client (Choice B) may not be appropriate without understanding the situation better. Escorting the client to his room (Choice C) may escalate the situation without addressing the underlying cause of the behavior, which can be better understood through active listening.

5. A client with schizophrenia is being discharged home after an extended stay in a psychiatric hospital. Which statement by the client indicates that further teaching about medication management is needed?

• A. “I will take my medication only when I feel like it.”
• B. “I need to follow up with my psychiatrist regularly.”
• C. “I will notify my healthcare provider if I experience side effects.”
• D. “I should avoid alcohol while on my medication.”

Correct answer: A

Rationale: The correct answer is A. This statement indicates a lack of understanding about medication management for schizophrenia. Medications for schizophrenia should be taken consistently as prescribed for optimal effectiveness, regardless of how the client feels. Choice B is a correct statement as regular follow-up with a psychiatrist is important for monitoring progress and adjusting treatment. Choice C demonstrates good awareness of potential side effects and the need for communication with healthcare providers. Choice D reflects appropriate knowledge as alcohol can interact with medications and may reduce their effectiveness.

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