Nursing Elites

1. A nurse working on a mental health unit receives a community call from a person who is tearful and states, 'I just feel so nervous all of the time. I don't know what to do about my problems. I haven't been able to sleep at night and have hardly eaten for the past 3 or 4 days.' The nurse should initiate a referral based on which assessment?

• A. Altered thought processes.
• B. Moderate levels of anxiety.
• C. Inadequate social support.
• D. Altered health maintenance.

Correct answer: B

Rationale: The nurse should initiate a referral based on moderate levels of anxiety (B) as the client reports feeling nervous all the time, sleep disturbances, poor appetite, and difficulty solving problems. These symptoms are indicative of significant anxiety levels. The client does not mention symptoms related to altered thought processes (A) or inadequate social support (C). There is insufficient information to suggest altered health maintenance (D) as a reason for referral in this scenario.

2. The nurse observes a female client with schizophrenia watching the news on TV. She begins to laugh softly and says, 'Yes, my love, I'll do it.' When the nurse questions the client about her comment, she states, 'The news commentator is my lover, and he speaks to me each evening. Only I can understand what he says.' What is the best response for the nurse to make?

• A. What do you believe the news commentator said to you?
• B. Let's watch the news on a different television channel.
• C. Does the news commentator have plans to harm you or others?
• D. The news commentator is not talking to you.

Correct answer: A

Rationale: The correct response for the nurse is to ask the client, 'What do you believe the news commentator said to you?' This is important to determine the content of the auditory hallucination and understand the client's perception. Choice B is incorrect as changing the TV channel does not address the underlying issue. Choice C is incorrect as it introduces a paranoid idea that the news commentator may have harmful intentions, which is not supported by the scenario. Choice D is incorrect as it dismisses the client's belief without exploring or validating her experience.

3. Which action should the nurse implement during the termination phase of the nurse-client relationship?

• A. Identify new problem areas.
• B. Confront changes not completed.
• C. Explore the client's past in depth.
• D. Help summarize accomplishments.

Correct answer: D

Rationale: During the termination phase of the nurse-client relationship, it is essential for the nurse to help summarize accomplishments. This action provides closure by reflecting on the progress and goals achieved during treatment. It reinforces the positive aspects of the therapeutic relationship and helps the client acknowledge their growth and achievements. Choices A, B, and C are incorrect. Identifying new problem areas is not appropriate during termination, as the focus should be on closure. Confronting changes not completed may create tension and disrupt the positive closure process. Exploring the client's past in depth is more suitable for earlier stages of the therapeutic relationship, not during termination.

4. The wife of a male client recently diagnosed with schizophrenia asks the nurse, 'What exactly is schizophrenia? Is my husband all right?' Which response is best for the nurse to provide to this family member?

• A. It sounds like you're worried about your husband. Let's sit down and talk.
• B. It is a chemical imbalance in the brain that causes disorganized thinking.
• C. Your husband will be just fine if he takes his medications regularly.
• D. I think you should talk to your husband's psychologist about this question.

Correct answer: B

Rationale: The best response for the nurse to provide to the wife of the client diagnosed with schizophrenia is to offer factual information. Choice B is the correct answer as it explains that schizophrenia is a mental disorder characterized by a chemical imbalance in the brain that causes disorganized thinking. This response provides a simple and accurate explanation of the condition. Choices A, C, and D are incorrect because they do not directly address the wife's question about what schizophrenia is. Choice A focuses on emotional support rather than providing information about the disorder. Choice C gives false reassurance without addressing the nature of schizophrenia. Choice D deflects the question by suggesting the wife speak to the psychologist, missing an opportunity to educate and support the family member.

5. A male client with alcohol use disorder is admitted for detoxification. The nurse knows that which symptom is a sign of severe alcohol withdrawal?

• A. Bradycardia
• B. Seizures
• C. Hyperglycemia
• D. Constipation

Correct answer: B

Rationale: Seizures are a sign of severe alcohol withdrawal and can be life-threatening, requiring immediate medical attention. Bradycardia, hyperglycemia, and constipation are not typically associated with severe alcohol withdrawal. Bradycardia is more commonly seen in opioid withdrawal, hyperglycemia could be due to other reasons like uncontrolled diabetes, and constipation is not a typical symptom of severe alcohol withdrawal.

Similar Questions