Nursing Elites

1. A nurse is caring for a client with depression who is prescribed fluoxetine (Prozac). The client reports difficulty sleeping. What is the most appropriate nursing intervention?

• A. Encourage the client to take short naps during the day.
• B. Suggest the client drink a warm beverage before bedtime.
• C. Recommend the client exercise immediately before bedtime.
• D. Advise the client to take a sleep aid nightly.

Correct answer: B

Rationale: The most appropriate nursing intervention for a client with difficulty sleeping due to depression and prescribed fluoxetine is to suggest the client drink a warm beverage before bedtime. This intervention can promote relaxation and help establish a bedtime routine, potentially improving sleep quality. Encouraging short naps during the day (Choice A) may disrupt the client's nighttime sleep schedule. Recommending exercise immediately before bedtime (Choice C) can have a stimulating effect, making it harder for the client to fall asleep. Advising the client to take a sleep aid nightly (Choice D) should only be done under the guidance of a healthcare provider due to potential interactions with fluoxetine.

2. A 40-year-old male client diagnosed with schizophrenia and alcohol dependence has not had any visitors or phone calls since admission. He reports he has no family that cares about him and was living on the streets prior to this admission. According to Erikson's theory of psychosocial development, which stage is the client in at this time?

• A. Isolation.
• B. Stagnation.
• C. Despair.
• D. Role confusion.

Correct answer: B

Rationale: The client is in Erikson's 'Generativity vs. Stagnation' stage (age 24 to 45). This stage involves maintaining intimate relationships and moving toward developing a family, which the client seems to be struggling with due to lack of visitors and family support. Choices (A), (C), and (D) are incorrect. Isolation typically occurs in young adulthood (age 18 to 25), Despair in maturity (age 45 to death), and Role confusion in adolescence (age 12 to 20). These stages reflect challenges individuals face if they do not successfully navigate their psychosocial developmental tasks.

3. Unresolved feelings related to loss are most likely to be recognized during which phase of the therapeutic nurse-client relationship?

• A. Working
• B. Trusting
• C. Orientation
• D. Termination

Correct answer: D

Rationale: Unresolved feelings related to loss are often recognized and explored during the termination phase of the nurse-client relationship. This phase involves preparing the client for separation from the nurse, which can trigger unresolved feelings related to loss. During the termination phase, clients may confront their emotions about ending the therapeutic relationship and may also revisit unresolved issues or losses that have surfaced during the course of therapy. Choices A, B, and C are incorrect because the working phase focuses on active problem-solving and goal achievement, the trusting phase emphasizes establishing rapport and building trust, and the orientation phase involves initial introductions and orientation to the therapeutic process, respectively.

4. A woman arrives in the Emergency Center and tells the nurse she thinks she has been raped. The client is sobbing and expresses disbelief that a rape could happen because the man is her best friend. After acknowledging the client's fear and anxiety, how should the nurse respond?

• A. I would be very upset and mad if my best friend did that to me.
• B. You must feel betrayed, but maybe you might have led him on?
• C. Rape is not limited to strangers and frequently occurs by someone who is known to the victim.
• D. This does not sound like rape. Did you change your mind about having sex after the fact?

Correct answer: C

Rationale: A victim of date rape or acquaintance rape is less prone to recognize what is happening because the incident usually involves persons who know each other and the dynamics are different than rape by a stranger. Choice (C) provides confrontation for the client's denial because the victim frequently knows and trusts the perpetrator. Nurses should not express personal feelings (Choice A) when dealing with victims. Choice B, suggesting that the client led on the rapist, indicates that the sexual assault was somehow the victim's fault. Choice D is judgmental and does not display compassion or establish trust between the nurse and the client.

5. A client with a diagnosis of schizophrenia is experiencing auditory hallucinations. What is the most appropriate nursing intervention?

• A. Ask the client to describe the voices and what they are saying.
• B. Tell the client that the voices are not real.
• C. Encourage the client to engage in reality-based activities.
• D. Ask the client to focus on positive thoughts instead of the voices.

Correct answer: C

Rationale: The most appropriate nursing intervention for a client with schizophrenia experiencing auditory hallucinations is to encourage them to engage in reality-based activities. This intervention helps manage auditory hallucinations by redirecting the client's focus away from the hallucinations. Choice A is not recommended as it may exacerbate the hallucinations or distress the client. Choice B is incorrect because denying the reality of the voices can invalidate the client's experiences. Choice D, asking the client to focus on positive thoughts, may not be effective in addressing the auditory hallucinations directly.

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