Nursing Elites

1. An older male client with schizophrenia is found smearing feces on the bathroom walls of the chronic mental health unit where he resides. What action should the RN implement?

• A. Explain that the feces belong in the toilet.
• B. Show the client how to clean the walls.
• C. Escort the client out of the bathroom.
• D. Assist the client to clean the walls.

Correct answer: C

Rationale: Escorting the client out of the bathroom is the most appropriate action to take in this situation. This helps prevent further inappropriate behavior and maintains hygiene, while avoiding reinforcement of the behavior. Option A, explaining that the feces belong in the toilet, may not be effective as the behavior is likely a manifestation of the client's condition rather than a lack of understanding. Option B, showing the client how to clean the walls, may not address the underlying issue and could potentially reinforce the behavior. Option D, assisting the client to clean the walls, may also reinforce the behavior and is not the best approach to managing the situation.

2. A female client with obsessive-compulsive personality disorder is admitted to the hospital for a cardiac catheterization. The afternoon before the procedure, the client begins to keep detailed notes of the nursing care she is receiving and reports her findings to the RN at bedtime. What action should the nurse implement?

• A. Explain to the client that her behavior invades the rights of the nursing staff.
• B. Ask the client to explain why she is keeping a detailed record of her nursing care.
• C. Teach the client strategies to control her obsessive-compulsive behavior.
• D. Encourage the client to express her feelings regarding the upcoming procedure.

Correct answer: B

Rationale: Asking the client to explain why she is keeping a detailed record of her nursing care is the most appropriate action for the nurse to take in this situation. Understanding the client’s motivations for keeping detailed records can provide insight into her obsessive-compulsive behaviors and help manage them effectively. This approach allows for a non-confrontational exploration of the behavior. Choice A is incorrect because it may be perceived as confrontational and does not address the underlying reasons for the behavior. Choice C is incorrect because teaching strategies to control behavior should come after understanding the client's motives. Choice D is incorrect as it does not directly address the behavior of keeping detailed records, which is the immediate concern that needs to be addressed.

3. 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.

4. What is the most appropriate intervention by the RN to address a client with obsessive-compulsive disorder (OCD) who repeatedly checks to see if the door is locked and asks for reassurance?

• A. Set a specific limit on the number of times the client can check the door.
• B. Help the client find an alternative activity to perform.
• C. Provide consistent reassurance that the door is locked.
• D. Ignore the checking behavior and focus on other behaviors.

Correct answer: A

Rationale: Setting a specific limit on the checking behavior is the most appropriate intervention for a client with OCD who repeatedly checks the door and seeks reassurance. This approach helps the client gradually reduce the compulsive behavior, promotes independence, and supports progress in treatment. Choice B is not the most suitable intervention as it does not directly address the compulsive checking behavior. Choice C, providing consistent reassurance, may reinforce the compulsive behavior and hinder treatment progress. Choice D of ignoring the behavior does not actively assist the client in managing their symptoms and addressing the underlying disorder.

5. The nurse is completing the admission assessment of an underweight adolescent admitted to the psychiatric unit with a diagnosis of depression. Which finding requires notification to the healthcare provider?

• A. Body mass index of 21
• B. Potassium level of 2.9 mEq/dL
• C. WBC count of 10,000/mm3
• D. Blood pressure of 110/70 mmHg

Correct answer: B

Rationale: The correct answer is B. A potassium level of 2.9 mEq/dL is critically low and requires immediate notification to the healthcare provider as it indicates a potential electrolyte imbalance, which can lead to serious cardiac arrhythmias and other complications. Choices A, C, and D are within normal ranges or not indicative of immediate life-threatening issues. A body mass index of 21 may be considered normal for some individuals, a WBC count of 10,000/mm3 is slightly elevated but not an urgent concern, and a blood pressure of 110/70 mmHg is within normal limits for an adolescent.

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