Nursing Elites

1. A client on an acute mental health unit reports hearing voices that are stating, "kill your doctor"?. Which of the following actions should the nurse take first?

• A. Encourage the client to participate in group therapy on the unit.
• B. Initiate one-to-one observation of the client.
• C. Focus the client on reality.
• D. Notify the provider of the client's statement.

Correct answer: B

Rationale: When a client experiences command hallucinations, such as being told to harm someone, the priority is ensuring the safety of the client and others. Initiating one-to-one observation allows for close monitoring and intervention to prevent harm. Encouraging participation in group therapy may not be appropriate or safe at this time. Focusing the client on reality may not be effective when experiencing hallucinations, and notifying the provider should come after immediate safety measures have been taken.

2. What information should be collected when assessing the health status of a community?

• A. Air pollution levels
• B. Number of health food stores
• C. Most common causes of death
• D. Education level of the individuals

Correct answer: C

Rationale: When assessing the health status of a community, it is crucial to gather data on various health measures such as the most common causes of death. This information helps in understanding the prevalent health issues within the community. Factors like air pollution levels, the number of health food stores, and the education level of individuals are important community aspects but do not directly reflect the health status of the community. Therefore, the correct answer is to collect data on the most common causes of death as it provides insights into the major health concerns affecting the community.

3. Which of the following clients have barriers to accessing healthcare?

• A. A 36-year-old client who must use a wheelchair for mobility
• B. A 44-year-old client who is visiting the United States on a visa from India
• C. An 81-year-old client who is unable to drive
• D. All of the above

Correct answer: D

Rationale: All of the provided clients have barriers to accessing healthcare. Clients with physical limitations, such as the 36-year-old client using a wheelchair, may face challenges in mobility and accessing healthcare facilities. The 44-year-old client from India visiting the United States on a visa may encounter barriers related to language, cultural differences, or insurance coverage. The 81-year-old client who is unable to drive may struggle with transportation to healthcare appointments. Therefore, all three clients face different barriers to accessing healthcare, making 'All of the above' the correct answer.

4. You are turning your patient in bed and notice that a confused and lethargic patient had loose car keys and lipstick in the bed and had been lying on them. What is this person at risk for due to all three of these factors: confusion, lethargy, and items in the bed?

• A. Falls
• B. Skin breakdown
• C. Apnea
• D. Lack of mobility

Correct answer: B

Rationale: This patient is at great risk for skin breakdown due to the presence of three specific risk factors: confusion, lethargy, and items in the bed. While confusion puts the patient at risk for falls, confusion and lethargy together may lead to a lack of mobility. However, skin breakdown is the primary concern in this scenario as it is associated with all three risk factors - confusion, lethargy, and the presence of items in the bed. Therefore, the correct answer is 'Skin breakdown'.

5. When a nurse is asked by a physician to speak to a colleague about their unprofessional behavior in front of a client but chooses not to confront the colleague and avoids the physician the next day, what type of conflict resolution is the nurse exhibiting?

• A. Accommodation
• B. Competition
• C. Avoidance
• D. Negotiation

Correct answer: C

Rationale: The nurse is exhibiting the conflict resolution strategy of avoidance. Avoidance involves ignoring the problem in the hope that it will go away on its own. In this scenario, the nurse avoids confronting the colleague and stays away from the physician, which does not address the issue directly. While avoidance may provide time for others to gain insight into the situation, it typically does not lead to a resolution of the underlying problems. Accommodation (A) involves yielding to the wishes of others, competition (B) entails pursuing one's own concerns at the expense of others, and negotiation (D) involves seeking a mutually agreeable solution through communication and compromise, none of which are demonstrated by the nurse in this situation.

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