Nursing Elites

1. A patient with major depression who has lost 20 pounds in one month, has chronic low self-esteem, and a plan for suicide. The patient has taken an antidepressant medication for 1 week. Which nursing intervention is most directly related to this outcome: 'Patient will refrain from gestures and attempts to harm self'?

• A. Implement suicide precautions.
• B. Frequently offer high-calorie snacks and fluids.
• C. Assist the patient to identify three personal strengths.
• D. Observe patient for therapeutic effects of antidepressant medication.

Correct answer: A

Rationale: Implementing suicide precautions is the most critical intervention in this scenario as it directly addresses the patient's safety and the prevention of self-harm. The patient's significant weight loss, chronic low self-esteem, suicide plan, and recent initiation of an antidepressant medication indicate a high risk of self-harm. Suicide precautions involve close monitoring, removing harmful objects, and ensuring a safe environment to prevent the patient from acting on suicidal thoughts. While offering high-calorie snacks and fluids, assisting the patient in identifying personal strengths, and observing for therapeutic effects of the antidepressant are important aspects of care, they do not directly address the immediate risk of self-harm that implementing suicide precautions does.

2. Which behavior indicates that the client has learned the most effective method to cope with anger?

• A. Goes for a long jog
• B. Talks about the anger
• C. Goes outside and screams
• D. Focuses on cause of anger

Correct answer: B

Rationale: The correct answer is 'Talks about the anger.' This response indicates that the client has learned a positive coping method, as discussing angry feelings is a healthier way of dealing with anger. Talking about anger allows for expression and communication, leading to a better understanding of the emotions involved. Going for a long jog or screaming outside may provide temporary relief, but they do not address the root cause or help in processing the emotions effectively. Focusing solely on the cause of anger without expressing feelings may lead to increased frustration and escalation of anger, rather than promoting constructive coping mechanisms.

3. A female client who is undergoing infertility testing is taught how to examine her cervical mucus. After listening to the instructions, the client says, 'That sounds gross. I don't think I can do it.' Which conclusion would the nurse make from this statement?

• A. The client is unduly fastidious.
• B. The client feels that having a baby is not that important.
• C. The client may be uncomfortable with performing manual examination of the genitals.
• D. The client is afraid that she is the cause of the infertility.

Correct answer: C

Rationale: The client's statement expressing discomfort with the procedure indicates a potential unease with performing a manual examination of her genitals. It is not uncommon for individuals to feel uncomfortable or anxious about such intimate procedures. The nurse should explore this further with the client to address any concerns or fears. The option stating that the client is unduly fastidious lacks evidence and is not supported by the client's statement. The assumption that the client does not value having a baby is not warranted based on the given statement. While self-blame is a common emotional response in cases of infertility, the client's statement does not directly suggest this as the primary concern in this scenario.

4. An older adult who recently began self-administration of insulin calls the nurse daily to review the steps that should be taken when giving an injection. The nurse has assessed the client's skills during two previous office visits and knows that the client is capable of giving the daily injection. Which response by the nurse is likely to be most helpful in encouraging the client to assume total responsibility for the daily injections?

• A. "I know you are capable of giving yourself the insulin."
• B. "Giving yourself the injection seems to make you nervous."
• C. "When I watched you give yourself the injection, you did it correctly."
• D. "Tell me what you want me to do to help you give yourself the injection at home."

Correct answer: C

Rationale: The most appropriate response by the nurse in this scenario is option C. By acknowledging and affirming the client's demonstrated ability to self-administer the injection correctly, the nurse is providing positive reinforcement. This positive reinforcement helps to build the client's confidence and encourages them to take total responsibility for their daily injections. Option A, while positive, does not specifically reinforce the client's behavior related to giving the injection. Option B focuses on the client's feelings of nervousness, which may not be helpful in promoting independence. Option D, by offering help without assessing the client's actual needs, reinforces dependence on the nurse rather than encouraging self-reliance.

5. The best way for a healthcare provider and a healthcare facility to control the effects of poor and disruptive patient behavior is to _________________.

• A. prevent it
• B. restrain the patient
• C. medicate the patient
• D. isolate the patient

Correct answer: A

Rationale: The most effective approach to managing poor and disruptive patient behavior is by preventing it proactively. This involves implementing strategies, communication techniques, and environmental modifications that address the underlying causes of the behavior. Restraint, medication, and isolation should only be used as a last resort when the patient or others are at risk of harm. Restraint and isolation are primarily used to ensure safety, while medication, especially when used solely to control behavior, can have adverse effects and is considered a measure of last resort. Therefore, prevention is crucial in promoting a therapeutic environment and fostering positive patient outcomes.

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