Nursing Elites

1. A client with depression 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 depression reporting difficulty sleeping is to suggest the client drink a warm beverage before bedtime. A warm beverage can promote relaxation and help establish a bedtime routine, which may aid in improving sleep quality. Encouraging short naps during the day (Choice A) may disrupt the client's nighttime sleep pattern. 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 considered after other non-pharmacological interventions have been attempted and in consultation with a healthcare provider due to potential side effects and risks associated with sleep aids.

2. A client with borderline personality disorder is admitted to the psychiatric unit after a suicide attempt. The client frequently expresses feelings of emptiness and fears of abandonment. What is the most therapeutic nursing approach for this client?

• A. Encourage the client to participate in all group activities.
• B. Set clear and consistent boundaries while providing empathy.
• C. Reassure the client that the staff will not abandon them.
• D. Explore the client's past relationships in depth.

Correct answer: B

Rationale: The most therapeutic nursing approach for a client with borderline personality disorder, who frequently expresses feelings of emptiness and fears of abandonment, is to set clear and consistent boundaries while providing empathy. This approach helps manage the client's fear of abandonment and feelings of emptiness, which are common in borderline personality disorder. Option A may overwhelm the client in a group setting without addressing their specific needs. Option C, while well-intentioned, may not fully address the underlying issues and may create dependency. Option D delves into the client's past relationships, which may be inappropriate and trigger emotional distress in a vulnerable client.

3. Physical examination of a 6-year-old reveals several bite marks in various locations on his body. X-ray examination reveals healed fractures of the ribs. The mother tells the nurse that her child is always having accidents. Which initial response by the nurse is most appropriate?

• A. I need to inform the healthcare provider about your child's tendency to be accident-prone.
• B. Tell me more specifically about your child's accidents.
• C. I must report these injuries to the authorities because they do not seem accidental.
• D. Boys this age always seem to require more supervision and can be quite accident-prone.

Correct answer: B

Rationale: (B) seeks more information in a non-threatening manner to gather additional details about the child's accidents. This response allows the nurse to explore the situation further without making assumptions. (A) fails to address the concerning findings and instead focuses on informing the healthcare provider. (C) jumps to conclusions without gathering more information, potentially causing unnecessary distress to the family. (D) dismisses the seriousness of the situation by attributing the injuries to common accidents for boys, missing the opportunity to delve deeper into the issue.

4. Which client information indicates the need for the nurse to use the CAGE questionnaire during the admission interview?

• A. Reports difficulties with short-term memory since experiencing a traumatic brain injury.
• B. Client's medication history includes frequent use of antidepressants.
• C. Describes self as a social drinker who consumes alcoholic beverages daily.
• D. Medical history includes that the client was recently sexually assaulted.

Correct answer: C

Rationale: The correct answer is C. Describing oneself as a social drinker who consumes alcoholic beverages daily raises concerns about potential alcohol abuse issues. The CAGE questionnaire is a tool used to screen for alcohol use disorder. Choice A is incorrect as memory difficulties post-traumatic brain injury do not directly indicate a need for the CAGE questionnaire. Choice B is incorrect as the use of antidepressants, while important to note, does not specifically warrant the use of the CAGE questionnaire. Choice D is incorrect as a recent sexual assault, while significant, does not directly relate to the need for alcohol abuse screening using the CAGE questionnaire.

5. A client with schizophrenia is experiencing distressful thoughts secondary to paranoia. Which intervention(s) should the LPN/LVN include in the plan of care? Select one intervention that does not apply.

• A. Avoid laughing when near the client
• B. Whisper when communicating near the client
• C. Increase socialization of the client among peers
• D. Have the client sign a written release of information form

Correct answer: B

Rationale: The correct intervention for a client with schizophrenia experiencing distressful thoughts secondary to paranoia is to avoid laughing when near the client. This is important as laughter can be misinterpreted and exacerbate the client's paranoia. Whispering when communicating near the client is not an appropriate intervention as it may lead the client to think secretive or negative information is being shared about them, further fueling their paranoia. Increasing socialization among peers can help provide support and reduce feelings of isolation, while having the client sign a written release of information form is not directly related to managing paranoia and distressful thoughts.

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