Nursing Elites

1. Which of the following is an appropriate tension-reduction intervention for a patient who may be escalating toward aggressive behavior?

• A. Asking to speak to someone
• B. Asking to be alone
• C. Listening to music
• D. All of the above

Correct answer: D

Rationale: All of the above interventions are appropriate tension-reduction techniques for a patient in the ICU. When a patient is escalating toward aggressive behavior, it is crucial to have a range of strategies to help de-escalate the situation. Asking to speak to someone can provide emotional support and an outlet for communication. Asking to be alone can help the patient have space and time to calm down. Listening to music can be soothing and distracting. These interventions, along with additional ones like walking the hallway, watching television, writing in a journal, or requesting a PRN medication, can be helpful. It is essential to involve the patient in developing the care plan to identify triggers and effective tension-reduction techniques. Patients in escalation may not always recognize the need for intervention, so staff must be observant and offer personalized techniques to address the situation effectively.

2. What is a common reason why clients abuse alcohol?

• A. To blunt reality
• B. To precipitate euphoria
• C. To promote social interaction
• D. To stimulate the central nervous system

Correct answer: A

Rationale: Clients often abuse alcohol to blunt reality. Alcohol, by depressing the central nervous system and distorting or altering reality, can reduce anxiety. It is not primarily used to precipitate euphoria; instead, it may lead to mood swings, impaired judgment, and aggressive behavior. While alcohol can be used as a social lubricant, individuals with alcohol use disorder often drink in isolation. Moreover, excessive alcohol consumption can result in inappropriate and aggressive behaviors that hinder social interactions. It's important to note that alcohol is a depressant, unlike stimulants such as amphetamines and cocaine.

3. 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.

4. While communicating with a client, the nurse determines that the client has realized the harmful effects of alcohol consumption and plans to stop drinking within 6 months. Which stage of the transtheoretical model of change would the nurse correlate the client's behavior with?

• A. Action
• B. Preparation
• C. Maintenance
• D. Contemplation

Correct answer: D

Rationale: The transtheoretical model of change defines changing patterns in individuals across five stages based on their readiness to change. The stages are precontemplation, contemplation, preparation, action, and maintenance. In the contemplation stage, the client acknowledges the benefits of change and considers making the change within the next 6 months. This aligns with the client's realization of the harmful effects of alcohol consumption and intent to stop drinking within 6 months. The action stage involves actively making changes, the preparation stage includes goal-setting with an intention to change within 60 days, and the maintenance stage focuses on sustaining changed behavior for at least 6 months and taking preventive measures to avoid relapse. Therefore, in this scenario, the client's behavior aligns with the contemplation stage of the transtheoretical model of change.

5. A client says, 'The doctors lied about me. They said I murdered my mother. You killed her. She died before I was born.' Which psychotic feature is the client experiencing?

• A. Ideas of grandeur
• B. Confusing illusions
• C. Persecutory delusions
• D. Auditory hallucinations

Correct answer: C

Rationale: The client is experiencing persecutory delusions, as she believes that others are blaming her for negative actions. This is not about ideas of grandeur, which involve feelings of greatness or power. Confusing illusions refer to misinterpretation of stimuli, which is not present in this scenario. Auditory hallucinations involve hearing voices, which is not the case here. In this case, the client is delusional, but not hallucinating.

Similar Questions