Nursing Elites

1. A teenaged client, a heroin addict, is admitted to the unit for detoxification. What intervention is most important for the nurse to initiate during the first 24 hours after admission?

• A. Assign the client to a teen support group.
• B. Assess intake and output.
• C. Monitor for wheezing and apnea.
• D. Limit visitors to family members only.

Correct answer: B

Rationale: Assessing intake and output is crucial during the first 24 hours after admission for detoxification. This helps the nurse monitor the client's hydration status and kidney function as the body goes through withdrawal from heroin. Option A is incorrect because joining a support group is beneficial but may not be the priority in the initial phase of detoxification. Option C, monitoring for wheezing and apnea, is important but not the most critical intervention during the first 24 hours. Option D, limiting visitors to family members only, is not directly related to the immediate needs of assessing intake and output.

2. A client with major depressive disorder is being treated with cognitive-behavioral therapy (CBT). Which client statement indicates that CBT is having a positive effect?

• A. "I understand now that my negative thoughts are not always true."
• B. "I still feel down, but I am able to go to work."
• C. "I have stopped taking my antidepressant medication."
• D. "I avoid situations that make me feel anxious."

Correct answer: A

Rationale: The correct answer is A. Recognizing and challenging negative thoughts is a fundamental aspect of cognitive-behavioral therapy (CBT). In this statement, the client demonstrates insight into the fact that their negative thoughts may not always be accurate, showing progress in reframing their thoughts. Choice B indicates some improvement in functioning but does not directly relate to the core principles of CBT. Choice C is concerning as abruptly stopping antidepressant medication can be detrimental to the client's well-being. Choice D reflects avoidance behavior, which is typically a target for intervention in CBT rather than a sign of positive progress.

3. A client, who is on a 30-day commitment to a drug rehabilitation unit, asks the nurse if he can go for a walk on the grounds of the treatment center. When he is told that his privileges do not include walking on the grounds, the client becomes verbally abusive. Which approach will the nurse take?

• A. Call a staff member to escort the client to his room.
• B. Tell the client to talk to his healthcare provider about his privileges.
• C. Remind the client of the unit rules.
• D. Ignore the client's inappropriate behavior.

Correct answer: C

Rationale: (C) is the correct approach in this situation as it reinforces unit rules, setting clear boundaries and expectations. By reminding the client of the unit rules, the nurse is helping to maintain a safe and structured environment within the drug rehabilitation unit. (A) is unnecessary since the client's behavior does not warrant immediate physical intervention. (B) is not ideal because the client's privileges have already been explained, and suggesting he speak to his healthcare provider may not address the immediate issue. (D) is not appropriate as addressing inappropriate behavior is essential in a therapeutic setting.

4. 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.

5. The parents of a nuclear family attending a support group for parents of adolescents are being assessed by the nurse. According to Erikson, these parents who are adapting to middle adulthood should exhibit which characteristic?

• A. Loss of independence.
• B. Increased self-understanding.
• C. Isolation from society.
• D. Development of intimate relationships.

Correct answer: B

Rationale: The correct answer is B: Increased self-understanding. According to Erikson's psychosocial development theory, middle adulthood is characterized by generativity, self-reflection, understanding, and acceptance. Middle-aged adults focus on guiding the next generation and finding meaning in their lives. Choices A and C are incorrect because loss of independence and isolation from society are maladaptive behaviors in middle adulthood. While developing and maintaining intimate relationships is important throughout life, the initial development of intimate relationships typically occurs during young adulthood, not middle adulthood.

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