Nursing Elites

1. A nurse working in the emergency room of a children's hospital admits a child whose injuries could have resulted from abuse. Which statement most accurately describes the nurse's responsibility in cases of suspected child abuse?

• A. Obtain objective data such as x-rays before reporting suspicions.
• B. Confirm suspicions of abuse with the physician.
• C. Report any case of suspected child abuse.
• D. Document injuries to confirm suspected abuse.

Correct answer: C

Rationale: The correct answer is C: 'Report any case of suspected child abuse.' Nurses are mandated reporters, which means they are legally obligated to report any suspicions of child abuse to appropriate authorities to ensure the child's safety. This responsibility overrides the need to gather additional data or confirm suspicions with others before reporting. Choice A is incorrect because delaying reporting to gather more data may risk the child's safety. Choice B is incorrect because reporting suspicions promptly is crucial, and waiting to confirm with another healthcare provider could delay necessary intervention. Choice D is incorrect as the priority is to report suspicions promptly rather than focusing on documenting injuries to confirm abuse.

2. Which diet selection by a client who is depressed and taking the MAO inhibitor tranylcypromine sulfate (Parnate) indicates to the nurse that the client understands the dietary restrictions imposed by this medication regimen?

• A. Hamburger, French fries, and chocolate milkshake.
• B. Liver and onions, broccoli, and decaffeinated coffee.
• C. Pepperoni and cheese pizza, tossed salad, and a soft drink.
• D. Roast beef, baked potato with butter, and iced tea.

Correct answer: D

Rationale: Roast beef, baked potato with butter, and iced tea are safe choices as they do not contain tyramine, which must be avoided with MAO inhibitors like Parnate. Tyramine-rich foods like aged cheeses, certain meats, and fermented products can cause a hypertensive crisis when combined with MAO inhibitors. Choices A, B, and C contain foods high in tyramine and are not recommended for individuals taking MAO inhibitors.

3. A client in the manic phase of bipolar disorder is pacing the hallway and talking rapidly. What is the best intervention for the nurse?

• A. Encourage the client to join a group activity.
• B. Offer the client a high-calorie snack and a drink.
• C. Direct the client to a quieter area of the unit.
• D. Instruct the client to sit down and relax.

Correct answer: B

Rationale: In the manic phase of bipolar disorder, clients often exhibit increased activity and may burn a lot of energy. Offering a high-calorie snack and a drink is the best intervention as it helps maintain their nutritional needs while allowing them to continue their activity. Encouraging the client to join a group activity (Choice A) may further stimulate their behavior. Directing the client to a quieter area (Choice C) might not address their energy expenditure. Instructing the client to sit down and relax (Choice D) may not be effective during the manic phase.

4. A woman brings her 48-year-old husband to the outpatient psychiatric unit and describes his behavior to the admitting nurse. She states that he has been sleepwalking, cannot remember who he is, and exhibits multiple personalities. The nurse knows that these behaviors are often associated with

• A. dissociative disorder.
• B. obsessive-compulsive disorder.
• C. panic disorder.
• D. post-traumatic stress disorder.

Correct answer: A

Rationale: The correct answer is A: dissociative disorder. Sleepwalking, amnesia, and multiple personalities are examples of detaching emotional conflict from one's consciousness, which is the definition of a dissociative disorder. Obsessive-compulsive disorder (B) is characterized by persistent, recurrent intrusive thoughts or urges (obsessions) and compulsions. Panic disorder (C) is characterized by acute attacks of anxiety. Post-traumatic stress disorder (D) involves re-experiencing psychologically distressing events.

5. A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. What action should the nurse implement?

• A. Attempt to ask the client simple questions.
• B. Postpone the client interview until the next day.
• C. Ask another nurse to talk with the client.
• D. Document the client's paranoid behavior.

Correct answer: A

Rationale: When a client is guarded, suspicious, and resistant to talking, it is important for the nurse to attempt to ask the client simple questions. Simple questions can help build rapport, establish trust, and create a non-threatening environment. This approach may ease the client into more detailed discussions while reducing feelings of suspicion. Postponing the interview may increase the client's anxiety and distrust, while asking another nurse to talk with the client may disrupt continuity of care and the establishment of a therapeutic relationship. Documenting the client's behavior is important for the client's medical record, but it should not be the first action taken in this situation.

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