Nursing Elites

1. A male client is admitted to the mental health unit because he was feeling depressed about the loss of his wife and job. The client has a history of alcohol dependency and admits that he was drinking alcohol 12 hours ago. Vital signs are: temperature, 100 F, pulse 100, and BP 142/100. The nurse plans to give the client lorazepam (Ativan) based on which priority nursing diagnosis?

• A. Risk for injury related to suicidal ideation.
• B. Risk for injury related to alcohol detoxification.
• C. Knowledge deficit related to ineffective coping.
• D. Health-seeking behaviors related to personal crisis.

Correct answer: B

Rationale: The most important nursing diagnosis is related to alcohol detoxification (B) because the client has elevated vital signs, a sign of alcohol detoxification. Giving lorazepam (Ativan) to address the elevated vital signs due to alcohol withdrawal is a priority. Addressing the risk for injury related to suicidal ideation (A) should come after stabilizing the client's physiological state. Both (C) and (D) can be addressed once immediate safety needs are met, but the priority is managing the alcohol detoxification to prevent potential complications.

2. A 45-year-old male client tells the nurse that he used to believe that he was Jesus Christ, but now he knows he is not. Which response is best for the nurse to make?

• A. Did you really believe you were Jesus Christ?
• B. I think you're getting well.
• C. Others have had similar thoughts when under stress.
• D. Why did you think you were Jesus Christ?

Correct answer: C

Rationale: Choice C is the best response because it validates the client's experience by acknowledging that others have had similar thoughts when under stress. This response helps normalize the client's past experiences without judgment, fostering a supportive and empathetic environment. Choices A and D may come off as judgmental or confrontational, potentially making the client feel misunderstood or defensive. Choice B, 'I think you're getting well,' does not address the client's past belief or provide the understanding and validation that Choice C offers.

3. A male client with bipolar disorder has not slept or eaten in four days. He paces and becomes increasingly agitated and loud while the nurse talks to his spouse. What intervention is the best for the nurse to implement at this time?

• A. Move to a quiet area and provide peanut butter with crackers.
• B. Walk with the client to the cafeteria and star as he eats lunch.
• C. Request a full lunch tray from the dietary department.
• D. Encourage the spouse to eat lunch with the client.

Correct answer: A

Rationale: In this situation, the best intervention for the nurse to implement is to move the client to a quiet area and provide peanut butter with crackers. The client's behavior indicates increasing agitation and loudness, which could be exacerbated by a noisy environment. Providing a quiet space can help reduce stimuli and promote a sense of calm. Additionally, offering a small, manageable snack like peanut butter with crackers can address the client's immediate needs for sustenance without overwhelming him. Choices B, C, and D do not address the client's current agitation and lack of sleep or food effectively, making them less appropriate interventions in this scenario.

4. 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.

5. On admission assessment, the nurse is obtaining subjective data about a client's sexual and reproductive status. The client states, 'I don't want to discuss this; it's private and personal.' Which response by the LVN/LPN is the most therapeutic?

• A. I'd hate being asked these sorts of questions too, but it's a necessary part of providing you with the best care.
• B. This is difficult for you to speak about, but I need this information from you in order to perform a complete assessment.
• C. I am a professional registered nurse, and, as such, I'll have you know that all your information is certainly kept confidential.
• D. I know that some of these questions are difficult for you, but, as a professional nurse, I am obligated to respect your confidentiality.

Correct answer: D

Rationale: The correct response is D. Respecting the client's privacy while acknowledging the difficulty of the situation and explaining the professional obligation to maintain confidentiality is the most therapeutic approach. This response shows empathy, understanding, and a commitment to confidentiality, which can help build trust and encourage the client to open up. Choices A, B, and C do not effectively address the client's concerns or emphasize the importance of confidentiality in a sensitive manner, making them less therapeutic responses in this situation.

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