Nursing Elites

1. A middle-aged female client with no previous psychiatric history is seen in the mental health clinic because her family describes her as having paranoid thoughts. On assessment, she tells the nurse, “I want to find out why these people are stalking me.” Which response should the nurse provide?

• A. It sounds like this experience is frightening for you.
• B. What makes you think people are stalking you?
• C. I know you are frightened, but no one is stalking you.
• D. Do you think someone is trying to harm you?

Correct answer: A

Rationale: The correct response for the nurse to provide is option A: 'It sounds like this experience is frightening for you.' This response acknowledges the client's feelings and emotions without directly challenging the delusion of being stalked. Option B is incorrect as it directly questions the client's belief, which can lead to increased defensiveness. Option C is incorrect as it denies the client's belief without addressing the underlying fear and can cause the client to feel misunderstood. Option D is incorrect as it directly asks about harm, which may not be the primary concern of the client at this moment.

2. 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.

3. A female client requests that her husband be allowed to stay in the room during the admission assessment. While interviewing the client, the nurse notes a discrepancy between the client’s verbal and nonverbal communication. What action should the nurse take?

• A. Pay close attention and document the nonverbal messages.
• B. Ask the client’s husband to interpret the discrepancy.
• C. Ignore the nonverbal behavior and focus on the client’s verbal messages.
• D. Integrate the verbal and nonverbal messages and interpret them as one.

Correct answer: A

Rationale: When a nurse observes a discrepancy between a client's verbal and nonverbal communication, it is essential to pay close attention and document the nonverbal messages. Nonverbal cues, such as body language and facial expressions, can provide valuable insights into the client's emotional state, feelings, and concerns that may not be expressed verbally. By documenting these nonverbal messages, the nurse can gain a more comprehensive understanding of the client's communication and address any potential underlying issues. Asking the client's husband to interpret the discrepancy (Choice B) may not always provide an accurate understanding of the client's nonverbal cues. Ignoring the nonverbal behavior (Choice C) could lead to missing important cues affecting the client's care. Integrating verbal and nonverbal messages (Choice D) is important, but initially focusing on documenting and understanding the nonverbal cues can enhance the nurse's assessment and communication with the client.

4. A client with obsessive-compulsive disorder (OCD) is receiving a new prescription for fluoxetine (Prozac). Which statement by the client indicates an understanding of this medication?

• A. “I should begin feeling less anxious within a few weeks.”
• B. “The drug will help me control my compulsive behaviors.”
• C. “I will need to have a weekly blood test to check my liver function.”
• D. “I should avoid foods that contain tyramine while taking this medication.”

Correct answer: B

Rationale: The correct answer is B. Fluoxetine, an SSRI, can help manage symptoms of OCD by assisting in controlling compulsive behaviors rather than directly reducing anxiety. The improvement in symptoms usually occurs over a few weeks. Choice A is incorrect as it provides a timeframe for anxiety improvement, which is not the primary goal of fluoxetine in OCD treatment. Choice C is incorrect as routine blood tests are not typically required with fluoxetine. Choice D is incorrect as avoiding tyramine-containing foods is more relevant for MAOIs, not SSRIs like fluoxetine.

5. Which therapeutic communication statement might a psychiatric-mental health registered nurse use when a patient's nursing diagnosis is altered thought processes?

• A. I know you say you hear voices, but I cannot hear them.
• B. Stop listening to the voices, they are NOT real.
• C. You say you hear voices, what are they telling you?
• D. Please tell the voices to leave you alone for now.

Correct answer: C

Rationale: Choice C is the correct answer because it acknowledges the patient's experience of hearing voices, showing empathy and exploring the content of the hallucinations. This type of therapeutic communication encourages the patient to express their thoughts and feelings without judgment. Choices A, B, and D are incorrect because they either deny the patient's experience, dismiss the hallucinations as not real, or suggest eliminating them, which can be perceived as invalidating the patient's feelings and experiences.

Similar Questions