Nursing Elites

1. A mental health worker (MHW) is caring for a client with escalating aggressive behavior. Which action by the MHW warrants immediate intervention by the nurse?

• A. Attempting to physically restrain the client.
• B. Telling the client to go to the quiet area of the unit.
• C. Using a loud voice to talk to the client.
• D. Remaining at a distance of 4 feet from the client.

Correct answer: A

Rationale: The correct answer is A: Attempting to physically restrain the client. Physical restraint should only be performed by trained professionals in a safe manner to prevent harm to the client and staff. In this scenario, the mental health worker should not attempt physical restraint, as it can escalate the situation and potentially lead to harm. Choices B, C, and D do not pose an immediate risk and can be part of de-escalation strategies. Choice B suggests guiding the client to a quiet area, choice C involves using a loud voice for better communication, and choice D indicates maintaining a safe distance, which are appropriate interventions to manage escalating aggressive behavior.

2. A client who is admitted to the mental health unit reports shortness of breath and dizziness. The client tells the nurse, “I feel like I’m going to die.” Which nursing problem should the nurse include in this client’s plan of care?

• A. Mood disturbance
• B. Moderate anxiety
• C. Altered thoughts
• D. Social isolation

Correct answer: B

Rationale: The correct answer is B: Moderate anxiety. When a client presents with symptoms such as shortness of breath, dizziness, and a fear of dying, it indicates moderate anxiety. Anxiety can manifest physically with symptoms like these. Mood disturbance (choice A) refers to a change in mood, while altered thoughts (choice C) relate to cognitive changes. Social isolation (choice D) involves a lack of social interaction, which is not the primary concern in this scenario where the client is experiencing acute anxiety symptoms.

3. What should the nurse initially assess when a high school girl reveals engaging in self-induced vomiting as a weight-control measure?

• A. National percentile of weight and height.
• B. Frequency of bingeing and purging behaviors.
• C. Perceptions of family and social relationships.
• D. School grades and extracurricular activities.

Correct answer: B

Rationale: The correct answer is assessing the frequency of bingeing and purging behaviors. This assessment is crucial in understanding the severity of the eating disorder and developing an appropriate treatment plan. Options A, C, and D are not the initial priority when dealing with a student engaging in harmful behaviors related to eating disorders. While weight and height, family relationships, and academic performance are important aspects to consider, the immediate focus should be on evaluating the behaviors directly linked to the reported issue.

4. When developing a plan of care for a male client admitted with delirium tremens, who is dehydrated, experiencing auditory hallucinations, has a bruised, swollen tongue, and is confused, what action should the RN include to ensure the client is physiologically stable?

• A. Encourage oral fluids.
• B. Monitor vital signs.
• C. Keep the room dark.
• D. Apply ice to his tongue.

Correct answer: B

Rationale: Monitoring vital signs is the priority action to ensure the physiological stability of a client with delirium tremens. In this scenario, the client's dehydration, confusion, and other symptoms necessitate close monitoring of vital signs to assess their condition accurately. Encouraging oral fluids (Choice A) is important for hydration but does not directly assess physiological stability. Keeping the room dark (Choice C) may help with hallucinations but is not the primary intervention for physiological stability. Applying ice to the tongue (Choice D) addresses a symptom but is less critical compared to monitoring vital signs in this situation.

5. While sitting in the day room of the mental health unit, a male adolescent avoids eye contact, looks at the floor, and talks softly when interacting verbally with the RN. The two trade places, and the RN demonstrates the client's behaviors. What is the main goal of this therapeutic technique?

• A. Initiate a non-threatening conversation with the client.
• B. Dialog about the ineffectiveness of his interactions.
• C. Allow the client to identify the way he interacts.
• D. Discuss the client's feelings when he responds.

Correct answer: C

Rationale: The main goal of the therapeutic technique described is to allow the client to identify the way he interacts. This technique helps promote self-awareness in the client by mirroring his behavior back to him, which can lead to insights about his own communication style. Option A is incorrect as the goal is not just to initiate conversation but to facilitate self-reflection. Option B is incorrect because the focus is not on discussing the ineffectiveness of the interactions but on self-awareness. Option D is incorrect as the primary aim is not to discuss the client's feelings but to help him recognize his interaction patterns.

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