Nursing Elites

1. Which intervention should the nurse use for a client who hallucinates, yells, and curses throughout the day?

• A. Ignore the client's behavior if the client is not harming anyone.
• B. Isolate the client until the behavior decreases or stops.
• C. Explain how the behavior affects other people on the unit.
• D. Seek to understand what the behavior means to the client.

Correct answer: D

Rationale: When a client experiences hallucinations, yells, and curses, it is essential to seek to understand the underlying meaning of their behavior. All behavior has significance, and understanding the client's perspective can guide appropriate interventions. Ignoring the behavior may exacerbate the situation and isolating the client could lead to increased anxiety and further acting out. Explaining the impact on others is not helpful in this scenario as the client is not intentionally hallucinating; yelling and cursing are responses to the hallucinations.

2. The nurse is caring for an Asian patient who is being admitted to the hospital. Which action would be most appropriate for the nurse to take when interviewing this patient?

• A. Avoid eye contact with the patient
• B. Observe the patient's use of eye contact
• C. Look directly at the patient when interacting
• D. Ask the patient's family member about the patient's cultural beliefs

Correct answer: B

Rationale: Observing the patient's use of eye contact will be most useful in determining the best way to communicate effectively with the patient. Different cultures have varying norms regarding eye contact, so by observing the patient, the nurse can adapt their communication style accordingly. Looking directly at the patient or avoiding eye contact may not be universally appropriate and could be misinterpreted. Asking a family member about the patient's cultural beliefs is not ideal as cultural beliefs can vary among individuals within the same cultural group. It is best to assess the patient directly to provide culturally sensitive care.

3. Which of the following best describes Eye Movement Desensitization and Reprocessing (EMDR)?

• A. A client follows the therapist's finger with their eyes while focusing on a negative thought or memory
• B. A client reads a story about a traumatic event and then visualizes the result
• C. A client focuses on a negative thought in their mind while tapping their fingers
• D. None of the above

Correct answer: A

Rationale: Eye Movement Desensitization and Reprocessing (EMDR) is a therapeutic approach used to address negative thoughts or traumatic memories, particularly in individuals with post-traumatic stress disorder. During EMDR, the client concentrates on a distressing thought or memory and the associated emotions while engaging in bilateral stimulation, often by moving their eyes back and forth. This bilateral stimulation can involve tracking the therapist's finger or other forms of sensory stimulation. Choice A is correct as it accurately describes the core process of EMDR. Choices B and C are incorrect as they do not involve the essential components of EMDR, which include eye movements or bilateral stimulation. Choice D is incorrect as EMDR is a specific therapeutic technique and not covered by selecting 'None of the above'.

4. Before assessing a new patient, a nurse is told by another healthcare worker, "I know that patient. No matter how hard we work, there isn't much improvement by the time of discharge."? The nurse's responsibility is to:

• A. document the other worker's assessment of the patient.
• B. assess the patient based on data collected from all sources.
• C. validate the worker's impression by contacting the patient's significant other.
• D. discuss the worker's impression with the patient during the assessment interview

Correct answer: B

Rationale: The correct answer is to assess the patient based on data collected from all sources. It is important for the nurse to gather information from various sources to form an objective assessment. Biased assessments by others should be evaluated as objectively as possible by the nurse, considering the potential impact of counter-transference. Documenting the other worker's assessment (Choice A) may be necessary for thorough documentation but should not influence the nurse's independent assessment. Validating the worker's impression by contacting the patient's significant other (Choice C) may not provide an accurate representation of the patient's condition. Discussing the worker's impression with the patient during the assessment interview (Choice D) can introduce bias and may not lead to an objective evaluation.

5. Which signs and symptoms would the nurse observe in a client with schizophrenia?

• A. Traumatic flashbacks and hypervigilance
• B. Depression and psychomotor retardation
• C. Loosened associations and hallucinations
• D. Ritualistic behavior and obsessive thinking

Correct answer: C

Rationale: In clients with schizophrenia, the nurse would observe loosened associations and hallucinations. Loosened associations refer to disorganized thinking where thoughts are not logically connected. Hallucinations involve perceiving things that are not based in reality. Traumatic flashbacks and hypervigilance are more indicative of post-traumatic stress disorder. Depression and psychomotor retardation are common in depression, not schizophrenia. Ritualistic behavior and obsessive thinking are typically seen in obsessive-compulsive disorders, not schizophrenia.

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