Nursing Elites

1. A female client with schizophrenia is experiencing auditory hallucinations. What is the most therapeutic response by the nurse?

• A. I don't hear any voices. They must be in your head.
• B. What are the voices telling you to do?
• C. You need to ignore the voices and focus on reality.
• D. I know the voices are real to you, but I don't hear them.

Correct answer: D

Rationale: Acknowledging the client's experience while gently presenting reality can help build trust and provide reassurance without reinforcing the hallucination.

2. Which action is most important for the nurse to implement during the initial interview for a client who is admitted to the mental health unit?

• A. Establish rapport in each phase of the nurse-client relationship.
• B. Determine the client's ability to communicate effectively.
• C. Reflect on previous psychiatric interviews the nurse has performed.
• D. Ensure data is collected and recorded in a systematic sequence.

Correct answer: A

Rationale: Establishing rapport is the most important action during the initial interview for a client admitted to the mental health unit. Building rapport helps create a trusting relationship between the nurse and the client, which is essential for effective communication and the success of the therapeutic relationship. Choice B, determining the client's ability to communicate effectively, is important but secondary to establishing rapport. Choice C, reflecting on previous psychiatric interviews, is not as critical during the initial interview with a new client. Choice D, ensuring data collection and recording in a systematic sequence, is important but comes after establishing rapport to foster a therapeutic environment.

3. Which client outcome indicates improvement for a client who is admitted with auditory hallucinations?

• A. Argues with the voices.
• B. Tells when voices decrease.
• C. Follows what the voices say.
• D. Tells the nurse what the voices say.

Correct answer: B

Rationale: The correct answer is B: 'Tells when voices decrease.' This outcome indicates improvement because it shows that the client is experiencing a reduction in auditory hallucinations. By communicating that the voices are decreasing, it suggests that the client's symptoms are improving and the treatment is effective. Choices A, C, and D are incorrect. Arguing with the voices (A) indicates ongoing engagement with the hallucinations, which is not a positive outcome. Following what the voices say (C) suggests compliance with the hallucinations, which is not indicative of improvement. Lastly, telling the nurse what the voices say (D) does not necessarily demonstrate a reduction in hallucinations or improvement in the client's condition.

4. A client with obsessive-compulsive disorder (OCD) spends several hours a day washing his hands. What is the best nursing intervention?

• A. Restrict the client's access to soap and water.
• B. Encourage the client to discuss their compulsions.
• C. Allow the client to continue the behavior until ready to stop.
• D. Schedule activities that distract the client from hand-washing.

Correct answer: B

Rationale: Encouraging the client to discuss their compulsions is the best nursing intervention when caring for a client with OCD who spends excessive time on hand-washing. This approach can help the client identify underlying anxieties and triggers associated with the compulsive behavior. Restricting access to soap and water (Choice A) can lead to increased anxiety and worsen the obsession. Allowing the client to continue the behavior (Choice C) can perpetuate the compulsive cycle. Scheduling distracting activities (Choice D) may provide temporary relief but does not address the root cause of the behavior.

5. What is the most important nursing intervention during the first 48 hours for a client with anorexia nervosa admitted to the hospital?

• A. Providing high-calorie, high-protein meals.
• B. Monitoring vital signs and electrolytes.
• C. Encouraging the client to talk about feelings.
• D. Observing for signs of purging.

Correct answer: B

Rationale: The most important nursing intervention during the first 48 hours for a client with anorexia nervosa is monitoring vital signs and electrolytes (B) to assess for life-threatening complications. This helps in early detection of any physiological imbalances that could lead to serious consequences. Providing high-calorie, high-protein meals (A) is important for nutritional rehabilitation but comes after ensuring the client's physical stability. Encouraging the client to talk about feelings (C) and observing for signs of purging (D) are relevant aspects of care but are not as critical as monitoring vital signs and electrolytes in the initial phase of treatment.

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