Nursing Elites

1. When assessing a client's behavior for potential aggression, what behavior would be recognized as the highest predictor of future violence?

• A. Pacing and restlessness
• B. Verbal threats
• C. History of violence
• D. Substance abuse

Correct answer: C

Rationale: A history of violence is considered the highest predictor of future violence. Clients who have a history of violent behavior are more likely to engage in violent acts in the future compared to those who exhibit other behaviors such as pacing, making verbal threats, or having substance abuse issues. Understanding a client's history of violence is crucial in assessing the risk of potential aggression and violence. Pacing and restlessness, verbal threats, and substance abuse can be concerning behaviors but do not carry the same predictive value for future violence as a documented history of violent behavior.

2. A client has been prescribed lorazepam (Ativan) for the treatment of anxiety. Which of the following instructions should the nurse include?

• A. Take the medication with food to avoid stomach upset.
• B. Avoid driving until you know how the medication affects you.
• C. Take the medication on an empty stomach.
• D. Double the dose if you miss a dose.

Correct answer: B

Rationale: The correct answer is B because lorazepam (Ativan) can cause dizziness and drowsiness, so the client should avoid driving until they know how the medication affects them. This instruction is crucial for ensuring the client's safety and preventing any potential accidents or harm. Choice A is incorrect because lorazepam does not necessarily need to be taken with food. Choice C is incorrect as it contradicts the usual recommendation of taking lorazepam with or without food. Choice D is incorrect and dangerous advice as doubling the dose of lorazepam can lead to overdose and serious complications.

3. Which behavior is consistent with therapeutic communication?

• A. Offering your opinion when asked to convey support.
• B. Summarizing the essence of the patient's comments in your own words.
• C. Interrupting periods of silence before they become awkward for the patient.
• D. Telling the patient they did well when you approve of their statements or actions.

Correct answer: B

Rationale: Summarizing the essence of the patient's comments in your own words is a key aspect of therapeutic communication as it demonstrates active listening and understanding. It shows the patient that their words have been heard and understood, fostering a sense of validation and empathy. Offering opinions, interrupting silence, or giving approval may not always align with the principles of therapeutic communication, which focus on patient-centered interactions and empathetic responses.

4. A client with obsessive-compulsive disorder (OCD) spends hours each day washing her hands. Which intervention should the nurse implement to help the client reduce this behavior?

• A. Encourage the client to set a time limit for washing hands.
• B. Encourage the client to wash hands only when necessary.
• C. Encourage the client to use hand sanitizer instead of washing.
• D. Encourage the client to explore the reasons behind the hand washing.

Correct answer: A

Rationale: Setting a time limit for hand washing is an effective intervention in managing obsessive-compulsive disorder (OCD) symptoms. By establishing boundaries around the behavior, the client can gradually work towards reducing the excessive hand washing and regaining control over the compulsion. Choice B is not as effective because it does not address the underlying compulsion. Choice C may not be helpful as it may not satisfy the client's need for cleanliness and could reinforce the behavior. Choice D, while important in therapy, may not be the most immediate intervention needed to address the excessive hand washing behavior.

5. Tomas is a 21-year-old male with a recent diagnosis of schizophrenia. Tomas's nurse recognizes that self-medicating with excessive alcohol is common in this disease and can co-occur along with:

• A. Generally good health despite the mental illness.
• B. An aversion to drinking fluids.
• C. Anxiety and depression.
• D. The ability to express his needs.

Correct answer: C

Rationale: Individuals with schizophrenia often turn to excessive alcohol consumption as a way to manage symptoms of anxiety and depression. This maladaptive coping mechanism can exacerbate the challenges associated with schizophrenia and may hinder effective treatment outcomes. Recognizing the presence of anxiety and depression alongside alcohol abuse is crucial for providing holistic care and support to individuals with schizophrenia.

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