Nursing Elites

1. A male client is brought to the emergency department by a police officer, who reports the client was disturbing the peace by running naked in the street, striking out at others, and smashing car windows. Which behaviors should the client demonstrate to determine if he should be evaluated for involuntary commitment?

• A. Threats to kill his friend.
• B. Disruptive behaviors in a community setting.
• C. Hears voices telling him to kill himself.
• D. Reports he has not needed a bath in 4 months.

Correct answer: D

Rationale: The client's dangerous and disruptive behaviors, along with auditory hallucinations of self-harm, suggest a need for involuntary commitment for his safety and that of others. Involuntary commitment may be warranted based on the client's poor hygiene and self-neglect, as it indicates an inability to care for himself, which can pose a risk to his well-being.

2. An emergency department nurse is caring for an adult client who is a victim of family violence. Which priority instruction would be included in the discharge instructions?

• A. Information regarding shelters
• B. Instructions regarding calling the police
• C. Instructions regarding self-defense classes
• D. Explaining the importance of leaving the violent situation

Correct answer: A

Rationale: The correct answer is A: Information regarding shelters. Providing information about shelters is crucial in cases of family violence as it ensures the client has a safe place to go after discharge, prioritizing their immediate safety. Option B, instructions regarding calling the police, may be necessary but ensuring a safe place to stay is more immediate. Option C, instructions regarding self-defense classes, may not be appropriate as the priority is to ensure the client's safety rather than teaching self-defense. Option D, explaining the importance of leaving the violent situation, is relevant but providing information on immediate shelter options is the priority.

3. A client with anorexia nervosa is being treated in an inpatient unit. Which intervention is a priority for the nurse?

• A. Encourage the client to exercise to build muscle mass.
• B. Provide liquid supplements between meals.
• C. Allow the client to choose their own meals.
• D. Monitor the client's weight daily.

Correct answer: D

Rationale: Monitoring the client's weight daily is a priority intervention for a nurse caring for a client with anorexia nervosa. Weight monitoring is crucial in assessing the client's progress and adjusting treatment as necessary to prevent complications such as refeeding syndrome, electrolyte imbalances, and cardiac issues. Encouraging exercise (Choice A) can exacerbate the client's unhealthy relationship with food and body image. Providing liquid supplements (Choice B) is important but may not be the priority over monitoring weight. Allowing the client to choose their own meals (Choice C) may not be suitable initially as they may make unhealthy choices or avoid meals altogether.

4. A client with bipolar disorder is being discharged with a prescription for lithium. What is the most important instruction the nurse should provide?

• A. Avoid foods high in sodium.
• B. Drink plenty of fluids, especially during hot weather.
• C. Take your medication with food.
• D. Monitor your blood pressure regularly.

Correct answer: B

Rationale: The correct answer is to instruct the client to drink plenty of fluids, especially during hot weather. Maintaining adequate hydration is crucial for clients taking lithium as dehydration can lead to lithium toxicity. Choice A is incorrect because while it is important to monitor sodium intake, staying hydrated is more critical. Choice C is incorrect as lithium is usually recommended to be taken with food to reduce stomach upset. Choice D is also important but not the most crucial instruction compared to ensuring proper hydration.

5. The nurse observes a female client with schizophrenia watching the news on TV. She begins to laugh softly and says, 'Yes, my love, I'll do it.' When the nurse questions the client about her comment, she states, 'The news commentator is my lover, and he speaks to me each evening. Only I can understand what he says.' What is the best response for the nurse to make?

• A. What do you believe the news commentator said to you?
• B. Let's watch the news on a different television channel.
• C. Does the news commentator have plans to harm you or others?
• D. The news commentator is not talking to you.

Correct answer: A

Rationale: The correct response for the nurse is to ask the client, 'What do you believe the news commentator said to you?' This is important to determine the content of the auditory hallucination and understand the client's perception. Choice B is incorrect as changing the TV channel does not address the underlying issue. Choice C is incorrect as it introduces a paranoid idea that the news commentator may have harmful intentions, which is not supported by the scenario. Choice D is incorrect as it dismisses the client's belief without exploring or validating her experience.

Similar Questions