Nursing Elites

1. Which action is most important for the nurse to implement during the initial interview for a client who is admitted to the mental health unit?

• A. Establish rapport in each phase of the nurse-client relationship.
• B. Determine the client's ability to communicate effectively.
• C. Reflect on previous psychiatric interviews the nurse has performed.
• D. Ensure data is collected and recorded in a systematic sequence.

Correct answer: A

Rationale: Establishing rapport is the most important action during the initial interview for a client admitted to the mental health unit. Building rapport helps create a trusting relationship between the nurse and the client, which is essential for effective communication and the success of the therapeutic relationship. Choice B, determining the client's ability to communicate effectively, is important but secondary to establishing rapport. Choice C, reflecting on previous psychiatric interviews, is not as critical during the initial interview with a new client. Choice D, ensuring data collection and recording in a systematic sequence, is important but comes after establishing rapport to foster a therapeutic environment.

2. A client who has recently been diagnosed with schizophrenia tells the LPN/LVN, 'I hear voices telling me to hurt myself.' What is the most appropriate nursing action?

• A. Encourage the client to ignore the voices.
• B. Tell the client that the voices will go away with medication.
• C. Monitor the client for signs of self-harm.
• D. Refer the client for a psychiatric evaluation.

Correct answer: D

Rationale: The correct answer is to refer the client for a psychiatric evaluation. The client's statement indicating hearing voices telling them to hurt themselves is a serious concern and suggests a risk for self-harm. Referring the client for a psychiatric evaluation is crucial for further assessment and intervention by mental health professionals. Choice A is incorrect because ignoring the voices may not address the client's safety. Choice B is incorrect as it oversimplifies the situation and does not address the immediate risk. Choice C is not as comprehensive as referring for a psychiatric evaluation, which is necessary in this situation.

3. During the admission assessment, a female client requests that her husband be allowed to stay in the room. While interviewing the client, the nurse notes a discrepancy between the client's verbal and nonverbal communication. What action should the nurse take?

• A. Pay close attention and document the nonverbal messages
• B. Ask the client's husband to interpret the discrepancy
• C. Ignore the nonverbal behavior and focus on the client's verbal messages
• D. Integrate the verbal and nonverbal messages and interpret them as one

Correct answer: A

Rationale: Noting both verbal and nonverbal cues is crucial to fully understand the client's condition and any potential underlying issues. Verbal communication may not always align with nonverbal cues, which can provide valuable insights into the client's emotional state and concerns. By paying close attention to and documenting the nonverbal messages, the nurse can gather a more comprehensive understanding of the client's situation. Asking the client's husband to interpret the discrepancy may not be appropriate as it could lead to misinterpretation or breach of confidentiality. Ignoring the nonverbal behavior could result in missing essential cues affecting the overall assessment. Integrating both verbal and nonverbal messages helps in forming a holistic view of the client's needs and concerns, enabling better care delivery.

4. A nurse working in the emergency room of a children's hospital admits a child whose injuries could have resulted from abuse. Which statement most accurately describes the nurse's responsibility in cases of suspected child abuse?

• A. Obtain objective data such as x-rays before reporting suspicions.
• B. Confirm suspicions of abuse with the physician.
• C. Report any case of suspected child abuse.
• D. Document injuries to confirm suspected abuse.

Correct answer: C

Rationale: The correct answer is C: 'Report any case of suspected child abuse.' Nurses are mandated reporters, which means they are legally obligated to report any suspicions of child abuse to appropriate authorities to ensure the child's safety. This responsibility overrides the need to gather additional data or confirm suspicions with others before reporting. Choice A is incorrect because delaying reporting to gather more data may risk the child's safety. Choice B is incorrect because reporting suspicions promptly is crucial, and waiting to confirm with another healthcare provider could delay necessary intervention. Choice D is incorrect as the priority is to report suspicions promptly rather than focusing on documenting injuries to confirm abuse.

5. A client with alcohol use disorder is admitted for detoxification. The nurse should monitor for which early sign of alcohol withdrawal?

• A. Seizures
• B. Visual hallucinations
• C. Tremors
• D. Delirium tremens

Correct answer: C

Rationale: Tremors are an early sign of alcohol withdrawal. They are caused by hyperactivity of the autonomic nervous system and are a common symptom during the early stages of withdrawal. Monitoring tremors is crucial as they can progress to more severe symptoms if not managed effectively. Seizures (Choice A) typically occur later in the withdrawal process and are a more severe symptom. Visual hallucinations (Choice B) usually manifest after tremors and are considered a mid-stage symptom. Delirium tremens (Choice D) is a severe form of alcohol withdrawal that typically occurs 2-3 days after the last drink, characterized by confusion, disorientation, and severe autonomic hyperactivity.

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