Nursing Elites

1. Over a period of several weeks, one male participant of a socialization group at a community day care center for the elderly monopolizes most of the group's time and interrupts others when they are talking. What is the best action for the nurse to take in this situation?

• A. Talk to the participant outside the group about his behavior during group meetings.
• B. Remind the participant to allow others in the group a chance to talk.
• C. Allow the group to handle the problem.
• D. Ask the participant to join another group.

Correct answer: C

Rationale: Allowing the group to handle the situation is the best action as it promotes group dynamics and empowerment, especially since the group is in the working phase. Talking to the participant individually (A) might be seen as manipulative. Reminding the participant (B) can come across as dictatorial and may not address the underlying issue. Asking the participant to join another group (D) does not address the problem at hand and avoids the opportunity for growth and conflict resolution within the current group.

2. A 52-year-old male client in the intensive care unit who has been oriented suddenly becomes disoriented and fearful. Assessment of vital signs and other physical parameters reveal no significant change, and the nurse formulates the diagnosis, 'Confusion related to ICU psychosis.' Which intervention would be best to implement?

• A. Move all machines away from the client's immediate area.
• B. Attempt to allay the client's fears by explaining the etiology of his condition.
• C. Cluster care so that brief periods of rest can be scheduled during the day.
• D. Extend visitation times for family and friends.

Correct answer: C

Rationale: In critical care environments, stressors can lead to isolation and confusion. Providing the client with scheduled rest periods (C) can help alleviate these symptoms. Moving all machines away (A) is impractical as they are often essential. Explaining the condition (B) may not be effective during acute confusion. Extending visitation times (D) can be overwhelming for the client in the ICU.

3. The nurse observes a female client with schizophrenia watching the news on TV. She begins to laugh softly and says, 'Yes, my love, I'll do it.' When the nurse questions the client about her comment, she states, 'The news commentator is my lover, and he speaks to me each evening. Only I can understand what he says.' What is the best response for the nurse to make?

• A. What do you believe the news commentator said to you?
• B. Let's watch the news on a different television channel.
• C. Does the news commentator have plans to harm you or others?
• D. The news commentator is not talking to you.

Correct answer: A

Rationale: The correct response for the nurse is to ask the client, 'What do you believe the news commentator said to you?' This is important to determine the content of the auditory hallucination and understand the client's perception. Choice B is incorrect as changing the TV channel does not address the underlying issue. Choice C is incorrect as it introduces a paranoid idea that the news commentator may have harmful intentions, which is not supported by the scenario. Choice D is incorrect as it dismisses the client's belief without exploring or validating her experience.

4. Several clients with chronic mental illness and multiple substance abuse histories live in a group residential home and attend a daycare mental health facility where group and individual therapies are provided. The RN finds the common bathroom at the facility with sputum on the walls, urine in the sink and on the floors, and the toilet stopped up with tissue, paper towels, and feces. What is the priority issue that the RN should address?

• A. Medication non-compliance.
• B. Number of bathroom facilities.
• C. Infection control.
• D. Acting out behaviors.

Correct answer: C

Rationale: The priority issue that the RN should address is infection control. The unsanitary conditions in the bathroom, with sputum on the walls, urine in the sink and on the floors, and the toilet clogged with tissue, paper towels, and feces, pose a significant health risk to all residents and staff. Addressing infection control is crucial to prevent the spread of diseases and ensure the well-being of everyone in the facility. Medication non-compliance is important but not the priority in this situation. The number of bathroom facilities, while relevant, is not the immediate concern when faced with unsanitary conditions. Acting out behaviors, though a valid concern in mental health settings, are not the priority when faced with such unsanitary and potentially infectious conditions.

5. The nurse suspects child abuse when assessing a 3-year-old boy and noticing several small, round burns on his legs and trunk that might be the result of cigarette burns. Which parental behavior provides the greatest validation for such suspicions?

• A. The parents' explanation of how the burns occurred is different from the child's explanation of how they occurred.
• B. The parents seem to dismiss the severity of the child's burns, saying they are very small and have not posed any problem.
• C. The parents become very anxious when the nurse suggests that the child may need to be admitted for further evaluation.
• D. The parents tell the nurse that the child was burned in a house fire which is incompatible with the nurse's observation of the type of burn.

Correct answer: D

Rationale: (D) provides the most validation for suspecting child abuse. The parent's explanation (subjective data) that the child was burned in a house fire is incompatible with the objective data observed by the nurse (small, round burns on the legs and trunk). (A) relies on subjective data, and the child's explanation might not accurately reflect the situation due to various factors like age or fear. The apparent lack of concern from the parents (B) is inconclusive as the nurse's interpretation of their reaction could be subjective. While parental anxiety (C) could hint at potential child abuse, it's important to note that most parents would naturally be anxious about their child's hospitalization, making it a less definitive indicator compared to the inconsistency in the explanation provided by the parents in option (D).

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