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 female client with obsessive-compulsive personality disorder is admitted to the hospital for a cardiac catheterization. The afternoon before the procedure, the client begins to keep detailed notes of the nursing care she is receiving and reports her findings to the RN at bedtime. What action should the nurse implement?

• A. Explain to the client that her behavior invades the rights of the nursing staff.
• B. Ask the client to explain why she is keeping a detailed record of her nursing care.
• C. Teach the client strategies to control her obsessive-compulsive behavior.
• D. Encourage the client to express her feelings regarding the upcoming procedure.

Correct answer: B

Rationale: Asking the client to explain why she is keeping a detailed record of her nursing care is the most appropriate action for the nurse to take in this situation. Understanding the client’s motivations for keeping detailed records can provide insight into her obsessive-compulsive behaviors and help manage them effectively. This approach allows for a non-confrontational exploration of the behavior. Choice A is incorrect because it may be perceived as confrontational and does not address the underlying reasons for the behavior. Choice C is incorrect because teaching strategies to control behavior should come after understanding the client's motives. Choice D is incorrect as it does not directly address the behavior of keeping detailed records, which is the immediate concern that needs to be addressed.

3. A young adult female visits the mental health clinic complaining of diarrhea, headache, and muscle aches. She is afebrile, denies chills, and all laboratory findings are within normal limits. During the physical assessment, the client tells the RN that her sister thinks she is neurotic and calls her a hypochondriac. Which response is best for the RN to provide?

• A. Unless your sister has a medical education, ignore her comments.
• B. I can hear that your sister comments are over-whelming you.
• C. Do you think it’s possible that you might be a hypochondriac?
• D. Besides your sister’s comments, what in your life is troubling you?

Correct answer: B

Rationale: Acknowledging the impact of the sister's comments on the client helps validate the client's feelings and supports therapeutic dialogue.

4. A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of risperidone (Risperdal). When the client walks to the nurse’s station in a literally contracted position, he states that something has made his body contort into a monster. What action should the nurse take?

• A. Medicate the client with the prescribed antipsychotic thioridazine (Mellaril).
• B. Offer the client a prescribed physical therapy hot pack for muscle spasms.
• C. Direct the client to occupational therapy to distract him from somatic complaints.
• D. Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia.

Correct answer: D

Rationale: The correct action for the nurse to take in this situation is to administer the prescribed anticholinergic benztropine (Cogentin) for dystonia. The client's symptoms of body contortion and feeling like a monster are indicative of acute dystonia, which can be a side effect of antipsychotic medications like risperidone. Benztropine can help alleviate these acute dystonic reactions. Choice A is incorrect because changing the antipsychotic medication at this point is not indicated. Choice B is not appropriate as the client's symptoms are likely due to acute dystonia rather than muscle spasms. Choice C is also not the best course of action as the client needs immediate intervention for the acute dystonic reaction.

5. A female client on a psychiatric unit is sweating profusely while vigorously doing push-ups and then running the length of the corridor several times before crashing into furniture in the sitting room. Picking herself up, she begins to toss chairs aside, looking for a red one to sit in. When another client objects to the disturbance, the client shouts, “I am the boss here. I do what I want.” Which nursing problem best supports these observations?

• A. Deficient diversional activity related to excess energy level.
• B. Disturbed personal identity related to grandiosity.
• C. Risk for activity intolerance related to hyperactivity.
• D. Risk for other-directed violence related to disruptive behaviors.

Correct answer: D

Rationale: The client's behavior of engaging in disruptive and aggressive actions, as well as claiming authority over others in the setting, indicates a risk for other-directed violence. This behavior poses a potential threat to the safety of others in the environment. Choice A is incorrect as the client's behavior is not solely indicative of a lack of diversional activities but rather a more serious issue. Choice B is incorrect as the behavior described does not primarily reflect disturbances in personal identity but rather displays of power and aggression. Choice C is incorrect as the client's actions do not suggest an intolerance to activity but rather an excessive and potentially harmful level of hyperactivity.

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