Nursing Elites

1. A client is being educated by a nurse about strategies for a safety plan for intimate partner violence. Which strategies should be included in the safety plan? (Select all that apply)

• A. Have a bag ready that contains extra clothes for self and children.
• B. Establish a code with family and friends to signal violence.
• C. Purchase a gun for protection.
• D. Attend a self-defense course focused on self-protection.

Correct answer: A

Rationale: The correct strategies for a safety plan for a victim of intimate partner violence include having a bag ready with essentials for self and children and establishing a code with family and friends to signal danger. These strategies can help the client prepare for emergencies and seek help discreetly. Purchasing a gun (Choice C) is not a safe or recommended strategy as it can escalate violence and pose more significant risks. Additionally, taking a self-defense course focused on self-protection (Choice D) is important for self-defense, but it should not involve retaliatory actions against the abuser with the intent to cause harm.

2. Which actions are likely to help promote the self-esteem of a male client with major depression?

• A. Ask the client about his long-term goals.
• B. Discuss the challenges of his medical condition.
• C. Include the client in determining treatment protocol.
• D. Encourage the client to engage in recreational therapy.

Correct answer: C

Rationale: Including the client in determining the treatment protocol is the most suitable action to promote the self-esteem of a male client with major depression. This approach empowers the client, involves him in decision-making regarding his care, and fosters a sense of control and self-worth. Option A, asking about his long-term goals, may not directly address his immediate self-esteem needs related to his current condition. Option B, discussing the challenges of his medical condition, may inadvertently focus on negative aspects and potentially lower self-esteem. Option D, encouraging engagement in recreational therapy, is beneficial but may not directly address the client's sense of control and self-worth in decision-making related to his treatment.

3. A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected outcome statement has the highest priority when planning nursing care?

• A. Excessive CNS stimulation will be reduced.
• B. Co-dependent behaviors will be decreased.
• C. Client’s level of consciousness will increase.
• D. Client will not demonstrate cross-addiction.

Correct answer: A

Rationale: The correct answer is A: 'Excessive CNS stimulation will be reduced.' During benzodiazepine withdrawal, the priority is to manage symptoms such as CNS hyperactivity, which can include agitation, anxiety, and seizures. Substitution therapy aims to minimize these withdrawal symptoms by providing a safer alternative to the benzodiazepine. Options B, C, and D are not the highest priority during benzodiazepine withdrawal. Decreasing co-dependent behaviors, increasing the client's level of consciousness, and preventing cross-addiction are important aspects of care but are not as critical as managing the potentially severe CNS stimulation.

4. A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit’s day room. What action should the nurse implement first?

• A. Administer a PRN sedative.
• B. Sit in the chair next to the client.
• C. Escort the client to his room.
• D. Listen to what the client is saying.

Correct answer: D

Rationale: When dealing with a client experiencing auditory hallucinations, it is crucial for the nurse to first listen to what the client is saying. Auditory hallucinations may hold significance to the client, and by actively listening, the nurse can gather information about the content and context of the hallucinations. This information helps the nurse assess the client's current state, emotional responses, and the potential triggers for the behavior. Administering a PRN sedative (Choice A) should not be the initial action as it may suppress important information and feelings the client is trying to communicate. Sitting next to the client (Choice B) may not be appropriate without understanding the situation better. Escorting the client to his room (Choice C) may escalate the situation without addressing the underlying cause of the behavior, which can be better understood through active listening.

5. The nurse is developing unit policies that will include nursing guidelines for maintaining a therapeutic milieu. Which interventions should be included when providing a therapeutic milieu in an inpatient setting?

• A. Opportunities to contribute to one's treatment plan.
• B. One-on-one dialogue sessions with the therapist.
• C. Regularly scheduled unit activities for peer interaction.
• D. Home visits to reintegrate into the family.

Correct answer: C

Rationale: The nurse is responsible for maintaining a therapeutic milieu in an inpatient setting, which involves creating a secure and structured environment that promotes client safety and offers opportunities for clients to learn healthy coping skills. Regularly scheduled unit activities for peer interaction help foster socialization, support, and a sense of community among clients. Choices A and B are valuable interventions in mental health care but do not directly relate to creating a therapeutic milieu in an inpatient setting. Choice D, home visits, would typically occur post-discharge and focus on community reintegration, rather than maintaining a therapeutic milieu within the inpatient setting.

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