Nursing Elites

1. The nurse completes an assessment of a client who is experiencing intimate partner violence (IPV). Which finding of the injuries should the nurse include in the documentation?

• A. The client’s significant other’s statement.
• B. Photographs.
• C. General description.
• D. A summary of the client’s feelings.

Correct answer: B

Rationale: In cases of intimate partner violence (IPV), documenting injuries is essential for legal and medical purposes. Photographs provide concrete and objective evidence of the injuries, leaving no room for interpretation or doubt. This visual documentation can be crucial in legal proceedings and serve as a critical component in ensuring the safety and well-being of the client. The significant other's statement (Choice A) may not accurately reflect the client's injuries and could be biased. A general description (Choice C) lacks the specificity and objectivity that photographs offer. Summarizing the client's feelings (Choice D) is important for emotional support but does not provide the concrete evidence needed in documenting IPV cases.

2. A male adolescent was admitted to the unit two days ago for depression. When the mental health nurse tries to interview the client to establish rapport, he becomes very irritated and sarcastic. Which action is best for the nurse to take?

• A. Offer to play a game of cards with the client.
• B. Report the behavior to the next shift.
• C. Document the behavior in the chart.
• D. Plan to talk with the client the next day.

Correct answer: A

Rationale: Offering to play a game of cards with the adolescent is the best action for the nurse to take in this situation. Engaging in an activity like playing a game can help establish rapport with the adolescent as it provides a more relaxed and non-threatening environment for communication. This approach can help the adolescent feel more comfortable and open up, as adolescents often find it easier to communicate when involved in an activity. Reporting the behavior to the next shift, documenting the behavior, or planning to talk with the client the next day do not directly address the immediate need to establish rapport and improve communication with the adolescent.

3. A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected outcome statement has the highest priority when planning nursing care?

• A. Excessive CNS stimulation will be reduced.
• B. Co-dependent behaviors will be decreased.
• C. Client’s level of consciousness will increase.
• D. Client will not demonstrate cross-addiction.

Correct answer: A

Rationale: The correct answer is A: 'Excessive CNS stimulation will be reduced.' During benzodiazepine withdrawal, the priority is to manage symptoms such as CNS hyperactivity, which can include agitation, anxiety, and seizures. Substitution therapy aims to minimize these withdrawal symptoms by providing a safer alternative to the benzodiazepine. Options B, C, and D are not the highest priority during benzodiazepine withdrawal. Decreasing co-dependent behaviors, increasing the client's level of consciousness, and preventing cross-addiction are important aspects of care but are not as critical as managing the potentially severe CNS stimulation.

4. A mental health worker is caring for a client with escalating aggressive behavior. Which action by the mental health worker warrants immediate intervention by the RN?

• A. Attempting to physically restrain the client.
• B. Remaining at a distance of 4 feet from the client.
• C. Telling the client to go to the quiet area of the unit.
• D. Using a loud voice to communicate with the client.

Correct answer: A

Rationale: Attempting to physically restrain the client without proper protocol and preparation can escalate the situation. This can lead to increased agitation and aggression in the client, potentially putting both the client and the mental health worker at risk. Remaining at a distance, directing the client to a quiet area, or using a loud voice are all strategies that can be used to de-escalate the situation and ensure safety without resorting to physical intervention. Therefore, the immediate intervention is needed when the mental health worker attempts to physically restrain the client. Option B, remaining at a distance, is a safe practice to ensure personal safety. Option C, directing the client to a quiet area, is a de-escalation technique to create a calmer environment. Option D, using a loud voice, may be necessary to establish boundaries and ensure the client can hear instructions clearly.

5. Gilbert, age 19, is described by his parents as a 'moody child' with an onset of odd behavior around age 14, which caused him to suffer academically and socially. Gilbert has lost the ability to complete household chores, is reluctant to leave the house, and is obsessed with the locks on the windows and doors. Due to Gilbert's early and slow onset of what is now recognized as schizophrenia, his prognosis is considered:

• A. Favorable with medication
• B. In the relapse stage
• C. Improvable with psychosocial interventions
• D. To have a less positive outcome

Correct answer: D

Rationale: In cases of early and slow onset of schizophrenia, the prognosis is generally less positive. This means that the outlook for individuals like Gilbert, who showed signs of schizophrenia at a young age, is often poorer. Option A is incorrect because while medication can help manage symptoms, the overall prognosis is still less favorable. Option B is incorrect since relapse stage typically refers to a period of worsening symptoms after initial improvement. Option C is incorrect because while psychosocial interventions can be beneficial, the underlying early and slow onset of schizophrenia indicates a less positive outcome.

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