Nursing Elites

1. An adult male client who was admitted to the mental health unit yesterday tells the nurse that microchips were planted in his head for military surveillance of his every move. Which response is best for the nurse to provide?

• A. You are in the hospital, and I am the nurse caring for you
• B. It must be difficult for you to control your anxious feelings
• C. Go to occupational therapy and start a project
• D. You are not in a war area now; this is the United States

Correct answer: C

Rationale: Delusions often generate fear and isolation, so the nurse should help the client participate in activities that avoid focusing on the false belief and encourage interaction with others.

2. A client with an eating disorder is planning to attend group meetings with Overeaters Anonymous. The LPN/LVN describes this group to the client, knowing that which finding(s) are characteristic of this form of self-help group? Select one that does not apply.

• A. A common goal is shared by all members
• B. Members are required to remain anonymous
• C. The leader is a professional mental health care provider
• D. Attendance must be prescribed by the health care provider

Correct answer: A

Rationale: Overeaters Anonymous is a self-help group characterized by shared goals among members to address eating disorders. This provides a supportive environment for personal change and growth. Choice B is incorrect as members are not required to remain anonymous in Overeaters Anonymous. Choice C is incorrect as the leader in such self-help groups is usually a member who has experienced similar issues, not necessarily a professional mental health care provider. Choice D is incorrect as attendance at Overeaters Anonymous meetings is voluntary and not prescribed by a healthcare provider.

3. A young adult female client is admitted to a psychiatric facility with a medical diagnosis of bulimia nervosa. Which nursing intervention has the highest priority?

• A. Schedule the client for group therapy with other clients with bulimia nervosa.
• B. Assign the client's care to a nurse with relevant experience in eating disorders.
• C. Monitor the client carefully for binging and purging activities.
• D. Assess and report the client's electrolyte status to the healthcare provider.

Correct answer: D

Rationale: The correct answer is D. Assessing and reporting the client's electrolyte status to the healthcare provider is the highest priority in a client with bulimia nervosa. Electrolyte imbalances, such as hypokalemia and metabolic alkalosis, are common due to purging behaviors associated with bulimia. Monitoring electrolyte levels is crucial to prevent life-threatening complications. Choices A, B, and C are incorrect because while therapy and monitoring for binging activities are important, addressing the electrolyte imbalances caused by purging behaviors takes precedence in the immediate care of a client with bulimia nervosa.

4. A 65-year-old female client complains to the nurse that recently she has been hearing voices. What question should the nurse ask this client first?

• A. Do you have problems with hallucinations?
• B. Are you ever alone when you hear the voices?
• C. Has anyone in your family had hearing problems?
• D. Do you see things that others cannot see?

Correct answer: B

Rationale: The nurse should first ask if the client is ever alone when she hears the voices. This question helps differentiate between potential auditory hallucinations and other causes like hearing loss. Choice A is not the best first question as it assumes the client is experiencing hallucinations without exploring other possibilities. Choice C is irrelevant to the immediate concern of hearing voices. Choice D pertains to visual hallucinations which are not described in the client's complaint of hearing voices.

5. A client is admitted to the mental health unit and reports taking extra anti-anxiety medication because, 'I'm so stressed out. I just wanted to go to sleep.' The nurse should plan one-on-one observation of the client based on which statement?

• A. What should I do? Nothing seems to help.
• B. I have been so tired lately and needed to sleep.
• C. I really think that I don't need to be here.
• D. I don't want to talk. Nothing matters anymore.

Correct answer: D

Rationale: The correct answer is D because expressing feelings of hopelessness or nihilism can be indicators of a deeper, possibly dangerous level of depression. Choice A is incorrect as it indicates seeking help, Choice B suggests fatigue, and Choice C implies denial of needing help, none of which directly signify severe depression warranting one-on-one observation.

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