Nursing Elites

1. During an admission assessment and interview, which channels of information communication should the healthcare professional be monitoring? Select all that apply.

• A. Auditory
• B. Visual
• C. Written
• D. Tactile

Correct answer: A

Rationale: During an admission assessment and interview, healthcare professionals should monitor auditory, visual, and non-verbal cues. Auditory communication involves listening to the patient's spoken words, tone of voice, and any other sounds they make. Visual communication includes observing the patient's facial expressions, body language, and gestures. Written communication, such as forms or notes, may also provide valuable information. Tactile communication pertains to touch, which is not typically utilized during an admission interview setting. While all channels of communication are important, in this context, auditory cues are particularly crucial for gathering verbal information during the assessment process, making choice A the correct answer. Visual cues and written information are also significant but may not be as critical as auditory cues during an interview. Tactile communication is generally not a primary channel used during a standard admission assessment and interview, hence it is not a key focus in this scenario.

2. A client with an eating disorder is being treated in a behavioral health unit. Which behavior would the nurse expect to see if the client is responding positively to the treatment?

• A. Adherence to the treatment plan and increased self-care activities.
• B. Increased isolation from others.
• C. Frequent complaining about treatment procedures.
• D. Refusal to eat meals provided by the unit.

Correct answer: A

Rationale: A positive response to treatment for a client with an eating disorder is indicated by adherence to the treatment plan and an increase in self-care activities. These behaviors show that the client is actively engaging in their treatment and taking steps towards recovery. Option B, increased isolation from others, is not indicative of a positive response to treatment as it may suggest withdrawal or avoidance. Option C, frequent complaining about treatment procedures, is not a behavior that signifies a positive response; it may indicate dissatisfaction or discomfort with the treatment. Option D, refusal to eat meals provided by the unit, is also not a positive response as it could suggest continued resistance to treatment and potential worsening of symptoms.

3. The RN on the evening shift receives a report that a client is scheduled for electroconvulsive treatment (ECT) in the morning. Which intervention should the RN implement the evening before the scheduled ECT?

• A. Hold all bedtime medications.
• B. Keep the client NPO after midnight.
• C. Implement elopement precautions.
• D. Give the client an enema at bedtime.

Correct answer: B

Rationale: Keeping the client NPO after midnight is the appropriate intervention before ECT to prevent complications during the procedure. Withholding food and fluids reduces the risk of aspiration and helps ensure the safety of the client. Option A (Hold all bedtime medications) is incorrect because medications may need to be given as prescribed unless specified otherwise by the healthcare provider. Option C (Implement elopement precautions) is unrelated to preparing a client for ECT and focuses on preventing a client from leaving the treatment area. Option D (Give the client an enema at bedtime) is unnecessary and not a standard pre-ECT preparation, making it an incorrect choice.

4. A client with an eating disorder tells the RN, 'I’ve been eating only 400 calories per day and have been taking diuretics to lose weight.' What is the RN’s best response?

• A. “Your diet is very harmful and needs to be changed immediately.”
• B. “It’s important to monitor your calorie intake carefully.”
• C. “Have you noticed any physical effects from this low-calorie diet?”
• D. “The diuretics could be causing your body to lose essential nutrients.”

Correct answer: D

Rationale: The correct response is D. By addressing the potential harm of diuretics and the low-calorie diet, the nurse effectively addresses both aspects of the client's disordered eating behavior. Choice A is too direct and does not provide information on the specific issue of diuretics. Choice B focuses solely on monitoring calorie intake without addressing the use of diuretics. Choice C inquires about physical effects but does not address the overall risks associated with diuretics and low-calorie intake.

5. A male client with schizophrenia tells the RN that he is being watched and that the television is speaking directly to him. Which response by the RN is appropriate?

• A. “The television cannot speak to you.”
• B. “That sounds very frightening for you.”
• C. “You should ignore the television.”
• D. “Why do you think the television is talking to you?”

Correct answer: B

Rationale: Option B is the correct response because it acknowledges the client's feelings and demonstrates empathy. By stating that the situation sounds frightening, the RN validates the client's experience without denying or reinforcing the delusion. This approach helps build rapport and trust with the client, which is essential in therapeutic communication. Options A and C are dismissive and may invalidate the client's experience, potentially worsening the trust relationship. Option D is confrontational and may make the client defensive, hindering effective communication and rapport-building.

Similar Questions