Nursing Elites

1. Which nurse statement defines boundaries in the orientation phase of the nurse-client relationship when talking to a depressed client who has just been admitted to the psychiatric unit?

• A. ''Tell me about the relationship that you have with your mother and father.''
• B. ''Hello! I'm Nurse Andrea. I'll introduce you around and help you settle in.''
• C. ''What is the main thing that you would like to work on during therapy?'
• D. ''I understand that you have been depressed. What can you tell me about that?'

Correct answer: B

Rationale: In the orientation phase of the nurse-client relationship, setting boundaries involves establishing the nurse's role and responsibilities while maintaining a professional distance. Option B demonstrates a clear boundary by introducing the nurse and offering assistance with settling in, which is appropriate for the initial phase of building rapport with the client. Choices A, C, and D delve into personal or therapeutic topics that are more suitable for the working phase of the relationship when the client's goals and problems are being addressed. Asking about the client's family relationships (Choice A), therapy focus (Choice C), or delving into the client's depression (Choice D) would be more relevant in later stages of the therapeutic process, once trust and rapport have been established during the orientation phase.

2. After informing an older client that an IV line needs to be inserted, the client becomes very apprehensive, loudly verbalizing a dislike for all healthcare providers and nurses. How should the nurse respond?

• A. Ask the client to remain quiet so the procedure can be performed safely.
• B. Concentrate on completing the insertion as efficiently as possible.
• C. Calmly reassure the client that the discomfort will be temporary.
• D. Tell the client a joke as a means of distraction from the procedure.

Correct answer: C

Rationale: The nurse should respond with a calm demeanor to help reduce the client's apprehension. By calmly reassuring the client that the discomfort from the procedure will be temporary, the nurse acknowledges the client's feelings and provides comfort. This response shows empathy and understanding, which can help build trust. Asking the client to remain quiet may escalate the situation and not address the client's underlying concerns. Concentrating solely on completing the insertion efficiently may overlook the client's emotional needs and may increase their anxiety. Telling a joke may not be appropriate in this serious situation and could be perceived as insensitive, failing to address the client's emotional distress effectively.

3. A client was admitted to the psychiatric unit after complaining to her friends and family that neighbors have bugged her home in order to hear all of her business. She remains aloof from other clients, paces the floor and believes that the hospital is a house of torture. Nursing interventions for the client should appropriately focus on efforts to

• A. Convince the client that the hospital staff is trying to help
• B. Help the client to enter into group recreational activities
• C. Provide interactions to help the client learn to trust staff
• D. Arrange the environment to limit the client's contact with other clients

Correct answer: C

Rationale: The correct nursing intervention for the client in this scenario is to provide interactions to help the client learn to trust staff. This approach focuses on building trust and establishing a therapeutic alliance between the client and the healthcare team. Choice A is incorrect because simply convincing the client that the hospital staff is trying to help may not address the underlying issue of trust. Choice B is not the priority at this stage as the client is exhibiting symptoms of paranoia and discomfort. Choice D may further isolate the client and hinder the therapeutic relationship. Therefore, the most appropriate intervention is to engage in interactions that promote trust and a therapeutic connection between the client and the staff.

4. A client becomes angry while waiting for a supervised break to smoke a cigarette outside and states, 'I want to go outside now and smoke. It takes forever to get anything done here!' Which intervention is best for the nurse to implement?

• A. Encourage the client to use a nicotine patch.
• B. Reassure the client that it is almost time for another break.
• C. Have the client leave the unit with another staff member.
• D. Review the schedule of outdoor breaks with the client.

Correct answer: D

Rationale: The best nursing action is to review the schedule of outdoor breaks and provide concrete information about the schedule. Suggesting a nicotine patch (Option A) is not suitable as the client wants to smoke. Reassuring the client about another break (Option B) does not address the client's frustration and does not promote effective communication. Having the client leave the unit with another staff member (Option C) is not appropriate as it goes against unit rules and does not address the client's concerns. Therefore, the most appropriate intervention is to review the schedule of outdoor breaks with the client to provide clarity and address the client's frustration effectively.

5. When doing an admission assessment for a patient, the nurse notices that the patient pauses before answering questions about the health history. Which action by the nurse is most appropriate?

• A. Interview a family member instead.
• B. Wait for the patient to answer the questions.
• C. Remind the patient that you have other patients who need care.
• D. Give the patient an assessment form listing the questions and a pen.

Correct answer: B

Rationale: When a patient pauses before answering questions about their health history, it is important for the nurse to be patient and wait for the patient to answer the questions. Patients from different cultures may take time to consider a question carefully before responding. By waiting patiently, the nurse shows respect for the patient's pace and helps foster a trusting relationship. Asking a family member to answer instead may not provide accurate information from the patient themselves. Reminding the patient about other patients needing care could make the patient feel rushed or unimportant. Giving the patient an assessment form and pen does not address the underlying reason for the pause and may come across as dismissive of the patient's need for time to respond thoughtfully.

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