Nursing Elites

1. An adolescent client is admitted to the psychiatric unit for self-harming behaviors. Which of the following is a priority nursing intervention?

• A. Assess the client’s suicidal ideation.
• B. Educate the client about healthy coping mechanisms.
• C. Encourage family therapy sessions.
• D. Provide a safe environment free of potential self-harm tools.

Correct answer: D

Rationale: The priority nursing intervention for an adolescent admitted for self-harming behaviors is to provide a safe environment free of potential self-harm tools. This intervention aims to prevent immediate harm to the client. Assessing suicidal ideation is important but ensuring physical safety takes precedence. While educating about healthy coping mechanisms is crucial for long-term management, immediate safety is the priority. Family therapy sessions are beneficial for holistic care but are not the immediate priority when the client's safety is at risk.

2. The nurse completes an assessment of a client who is experiencing intimate partner violence (IPV). Which finding of the injuries should the nurse include in the documentation?

• A. The client’s significant other’s statement.
• B. Photographs.
• C. General description.
• D. A summary of the client’s feelings.

Correct answer: B

Rationale: In cases of intimate partner violence (IPV), documenting injuries is essential for legal and medical purposes. Photographs provide concrete and objective evidence of the injuries, leaving no room for interpretation or doubt. This visual documentation can be crucial in legal proceedings and serve as a critical component in ensuring the safety and well-being of the client. The significant other's statement (Choice A) may not accurately reflect the client's injuries and could be biased. A general description (Choice C) lacks the specificity and objectivity that photographs offer. Summarizing the client's feelings (Choice D) is important for emotional support but does not provide the concrete evidence needed in documenting IPV cases.

3. A client in the emergency department presents with confusion, disorientation, and agitation after drinking alcohol. Which diagnostic test should the nurse anticipate to assess for potential complications?

• A. Complete blood count (CBC)
• B. Electrolyte panel
• C. Liver function tests
• D. Urinalysis

Correct answer: B

Rationale: The correct answer is an electrolyte panel. When a client presents with confusion, disorientation, and agitation after drinking alcohol, it indicates potential complications such as electrolyte imbalances. Monitoring electrolyte levels is crucial in these cases to detect and address abnormalities that may result from alcohol intake. While a complete blood count (choice A) may provide some valuable information, it is not the primary test to assess for alcohol-related complications presenting with these symptoms. Liver function tests (choice C) are more specific for assessing liver damage due to chronic alcohol use rather than immediate complications. Urinalysis (choice D) may help detect some issues but is not the most appropriate initial test to assess for potential complications in this scenario.

4. During a group session on anger management, a male adolescent client is fidgety, interrupts peers, and talks about his pets at home. What action should the nurse take?

• A. Allow the client to leave and return in 10 minutes.
• B. Explore the client’s feelings about his pets and home life.
• C. Encourage his peers to help involve him in the activity.
• D. Redirect him by encouraging him to read from the handout.

Correct answer: D

Rationale: The best nursing action in this scenario is to redirect the client by encouraging him to read from the handout. This approach helps refocus the client's attention on the topic being discussed, which is anger management. Choice A is not appropriate as it may disrupt the group session and does not address the client's behavior. Choice B, while important in understanding the client's background, does not address the immediate disruptive behavior. Choice C involves others to manage the client's behavior instead of direct intervention by the nurse, which may not be effective in this situation.

5. Gilbert, age 19, is described by his parents as a 'moody child' with an onset of odd behavior around age 14, which caused him to suffer academically and socially. Gilbert has lost the ability to complete household chores, is reluctant to leave the house, and is obsessed with the locks on the windows and doors. Due to Gilbert's early and slow onset of what is now recognized as schizophrenia, his prognosis is considered:

• A. Favorable with medication
• B. In the relapse stage
• C. Improvable with psychosocial interventions
• D. To have a less positive outcome

Correct answer: D

Rationale: In cases of early and slow onset of schizophrenia, the prognosis is generally less positive. This means that the outlook for individuals like Gilbert, who showed signs of schizophrenia at a young age, is often poorer. Option A is incorrect because while medication can help manage symptoms, the overall prognosis is still less favorable. Option B is incorrect since relapse stage typically refers to a period of worsening symptoms after initial improvement. Option C is incorrect because while psychosocial interventions can be beneficial, the underlying early and slow onset of schizophrenia indicates a less positive outcome.

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