Nursing Elites

1. A male employee who is assessed weekly in the employee clinic for blood pressure because of a history of hypertension tells the nurse that he is so upset with one of his co-workers that he would like to shoot him. What action should the nurse take first?

• A. Determine if the client has a weapon available for use.
• B. Inform the health care provider of the threat to harm a co-worker.
• C. Notify security of the client's intention to harm a co-worker.
• D. Have the employee escorted to a mental health facility.

Correct answer: A

Rationale: Determining if the client has access to a weapon is critical for immediate safety and to prevent potential harm.

2. A client with schizophrenia is experiencing delusions. What is the most appropriate nursing intervention?

• A. Encourage the client to explore the delusions in depth.
• B. Tell the client that the delusions are not real.
• C. Explore the underlying meaning of the delusions.
• D. Distract the client from the delusions and focus on reality.

Correct answer: D

Rationale: The most appropriate nursing intervention for a client with schizophrenia experiencing delusions is to distract the client from the delusions and focus on reality. Encouraging the client to explore the delusions in depth (Choice A) may worsen the delusions. Telling the client that the delusions are not real (Choice B) can lead to confrontation and disbelief. Exploring the underlying meaning of the delusions (Choice C) may not be effective during acute episodes of delusions; hence, distracting the client and refocusing on reality is the most suitable intervention.

3. 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.

4. 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.

5. When a client with major depressive disorder expresses feelings of worthlessness and hopelessness, what is the nurse's priority intervention?

• A. Encourage the client to engage in recreational activities.
• B. Suggest the client keep a journal of their thoughts and feelings.
• C. Assess the client for suicidal ideation.
• D. Provide the client with positive affirmations.

Correct answer: C

Rationale: The correct answer is to assess the client for suicidal ideation. When a client expresses feelings of worthlessness and hopelessness, it is crucial to evaluate the risk of self-harm. Encouraging recreational activities (choice A) or suggesting journaling (choice B) may be helpful interventions but assessing for suicidal ideation takes precedence due to the immediate risk of harm. Providing positive affirmations (choice D) is not the priority when safety is a concern.

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