Nursing Elites

1. The client with schizophrenia believes the news commentator is her lover and speaks to her. What is the best response for the nurse to make?

• A. What do you believe the news commentator said to you?
• B. Let's switch to a different news channel.
• C. Is the news commentator planning to harm you or others?
• D. The news commentator is not communicating with you.

Correct answer: A

Rationale: The correct response is to ask the client what she believes the news commentator said, as it helps the nurse assess the client's perception and delve into her delusions without being confrontational. Choice B is not helpful in addressing the client's delusions. Choice C jumps to conclusions about potential harm without assessing the client's beliefs. Choice D is dismissive and does not address the client's reality.

2. A client with bipolar disorder is admitted to the psychiatric unit in a manic state. What is the most therapeutic nursing intervention?

• A. Allow the client to engage in any activity they choose.
• B. Provide a structured environment with reduced stimuli.
• C. Encourage the client to express their thoughts freely.
• D. Place the client in a room with another client for socialization.

Correct answer: B

Rationale: During a manic state, individuals with bipolar disorder may exhibit hyperactivity, impulsivity, and reduced need for sleep. Providing a structured environment with reduced stimuli is the most therapeutic nursing intervention as it can help manage the client's excessive energy and prevent overstimulation. Choice A is incorrect as allowing the client to engage in any activity they choose may exacerbate their symptoms or lead to risky behaviors. Choice C, encouraging the client to express their thoughts freely, may not be appropriate during a manic state as it can further escalate their racing thoughts. Choice D, placing the client in a room with another client for socialization, may not be beneficial during a manic episode as it could increase stimulation and potentially lead to agitation.

3. A client with a diagnosis of schizophrenia is experiencing auditory hallucinations. What is the most appropriate nursing intervention?

• A. Ask the client to describe the voices and what they are saying.
• B. Tell the client that the voices are not real.
• C. Encourage the client to engage in reality-based activities.
• D. Ask the client to focus on positive thoughts instead of the voices.

Correct answer: C

Rationale: The most appropriate nursing intervention for a client with schizophrenia experiencing auditory hallucinations is to encourage them to engage in reality-based activities. This intervention helps manage auditory hallucinations by redirecting the client's focus away from the hallucinations. Choice A is not recommended as it may exacerbate the hallucinations or distress the client. Choice B is incorrect because denying the reality of the voices can invalidate the client's experiences. Choice D, asking the client to focus on positive thoughts, may not be effective in addressing the auditory hallucinations directly.

4. A client with obsessive-compulsive disorder (OCD) spends hours checking and rechecking the locks on the doors. What is the best nursing intervention?

• A. Allow the client to continue the behavior to reduce anxiety.
• B. Encourage the client to discuss the thoughts and feelings behind the behavior.
• C. Prevent the client from checking the locks to break the cycle.
• D. Schedule specific times for the client to check the locks.

Correct answer: B

Rationale: The best nursing intervention for a client with OCD who spends excessive time checking locks is to encourage the client to discuss the thoughts and feelings behind the behavior. By exploring the underlying anxiety and triggers, the client can gain insight and work towards behavior modification. Choice A is incorrect because enabling the behavior does not address the underlying issues. Choice C is incorrect as it may lead to increased anxiety and distress. Choice D is incorrect as it does not address the root cause of the behavior.

5. A client in a long-term care facility who has multiple sclerosis is embarrassed about the need to use a wheelchair and the muscle spasms that are readily visible in her legs. Which approach is therapeutic in assisting the client to cope?

• A. Keep the client in her room as much as possible
• B. Assist the client with all activities of daily living
• C. Tell the client that many of the people in the facility have these same sorts of problems
• D. Encourage and praise perseverance in performing ADLs, and assist the client to dress and groom daily

Correct answer: D

Rationale: Encouraging and praising the client's perseverance in performing activities of daily living (ADLs) is therapeutic as it helps the client maintain a sense of normalcy and dignity, thus supporting their psychosocial well-being. This approach acknowledges the client's struggles while empowering them to maintain their independence and self-care. Choices A and C are incorrect as they do not address the client's emotional needs and may contribute to further isolation and distress. Choice B, while important, does not specifically address the client's feelings of embarrassment and the need for emotional support.

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