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 healthcare provider is evaluating a client's response to a new antianxiety medication. Which client statement indicates a positive response to the medication?

• A. “I feel more relaxed and less anxious.”
• B. “I am sleeping less and feel more energetic.”
• C. “I have not noticed any changes in my anxiety levels.”
• D. “I have more difficulty concentrating than before.”

Correct answer: A

Rationale: The correct answer is A: “I feel more relaxed and less anxious.” A positive response to antianxiety medication is characterized by reduced anxiety and increased relaxation. Choice B, which mentions sleeping less and feeling more energetic, suggests potential side effects rather than a positive response to the medication. Choice C indicates no change in anxiety levels, which is not indicative of a positive response. Choice D, mentioning difficulty concentrating, is also a sign of a negative response to antianxiety medication as it may suggest cognitive impairment.

3. A client with schizophrenia is exhibiting visual and auditory hallucinations. What should be the RN’s initial intervention?

• A. Instruct the client to ignore the hallucinations.
• B. Encourage the client to describe the hallucinations in detail.
• C. Assess the client’s perception of the hallucinations.
• D. Provide reassurance that the hallucinations are not real.

Correct answer: C

Rationale: The correct initial intervention for a client with schizophrenia exhibiting visual and auditory hallucinations is to assess the client’s perception of the hallucinations. This step is crucial as it helps the RN determine the severity of the hallucinations and the best course of action for management and intervention. Instructing the client to ignore the hallucinations (Choice A) may not be effective as the hallucinations may be distressing and overwhelming. Encouraging the client to describe the hallucinations in detail (Choice B) may potentially worsen the symptoms or trigger further distress. Providing reassurance that the hallucinations are not real (Choice D) may not be appropriate as the client may genuinely believe in their reality, and this reassurance may not address the underlying issues causing the hallucinations.

4. A client with schizophrenia explains that she has 20 children and then very seriously points to the nurse and explains that she is one of them. What is the most therapeutic response for the nurse to provide?

• A. Let’s go ask another nurse if this is true.
• B. My name tag shows that I am a nurse here.
• C. I cannot possibly be one of your children.
• D. I know that you don’t have 20 children.

Correct answer: B

Rationale: Option B, 'My name tag shows that I am a nurse here,' is the most appropriate response as it provides clear and factual information to help the client differentiate between reality and delusion. By pointing out a concrete piece of evidence, the nurse can gently guide the client back to reality without directly challenging or contradicting their belief. Option A, 'Let’s go ask another nurse if this is true,' delays addressing the issue and doesn't provide immediate clarification. Option C, 'I cannot possibly be one of your children,' directly contradicts the client's statement and may increase distress. Option D, 'I know that you don’t have 20 children,' does not address the client's belief and can be perceived as dismissive.

5. A client with borderline personality disorder is admitted to the psychiatric unit. Which behavior should the nurse prioritize in the care plan?

• A. Self-harming behavior.
• B. Difficulty with interpersonal relationships.
• C. Impulsive spending and substance abuse.
• D. Inconsistent adherence to the treatment regimen.

Correct answer: A

Rationale: Self-harming behavior is the priority in the care plan for a client with borderline personality disorder. This behavior poses an immediate risk to the client's safety and requires prompt intervention. Difficulty with interpersonal relationships, impulsive spending, and substance abuse are also common in borderline personality disorder; however, self-harming behavior takes precedence due to its potential for severe harm. Inconsistent adherence to the treatment regimen, though important, is not as urgent as addressing the immediate safety concerns related to self-harm.

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