Nursing Elites

1. Which thought process would the nurse document the mental health client is experiencing after the client says, 'The FBI is out to kill me'?

• A. Hallucinations
• B. Error in judgment
• C. Delusion of persecution
• D. Self-accusatory delusion

Correct answer: C

Rationale: The nurse would document that the client is experiencing a delusion of persecution. A delusion of persecution is a fixed and firm belief of being harassed, in danger, or at the mercy of others, as illustrated by 'The FBI is out to kill me.' Hallucinations are perceived experiences that occur without actual sensory stimulation. Error in judgment refers to poor decision-making, not a distortion of reality like a delusion. A self-accusatory delusion involves accepting blame for an act that was never committed or a feeling that was never acted on. Therefore, the correct choice is 'Delusion of persecution.'

2. Which behavior best indicates that the client has received adequate preparation for the scheduled diagnostic studies?

• A. Asks for the tests to be explained again
• B. Checks the appointment card multiple times
• C. Arrives early and waits quietly to be called for the tests
• D. Paces back and forth in the hallway on the morning of the tests

Correct answer: C

Rationale: The correct answer is arriving early and waiting quietly to be called for the tests. This behavior indicates that the client is prepared, as early arrival suggests an expected degree of anxiety and the quiet waiting indicates a lower level of anxiety and adequate preparation. Asking for the tests to be explained again may signal inadequate explanation, nervousness, or poor memory. Checking the appointment card repeatedly or pacing up and down the hallway indicate a high level of anxiety, which could be associated with inadequate teaching. Nurses providing preprocedural teaching should assess for anxiety related to procedures, coping mechanisms, and retention of information post-teaching. If issues are identified, strategies such as paraphrasing information, having a support person present, seeking advice from someone who has undergone the procedure, or visiting the test center beforehand can be utilized.

3. A client asks the nurse, 'Should I tell my partner that I just found out I'm human immunodeficiency virus (HIV) positive?' Which is the nurse's most appropriate response?

• A. Do not tell your partner unless asked.
• B. This is a decision you alone can make.
• C. You are having difficulty deciding what to say.
• D. Tell your partner that you don't know how you became sick.

Correct answer: C

Rationale: The most appropriate response for the nurse in this situation is to acknowledge the client's struggle in deciding what to communicate to their partner. By stating 'You are having difficulty deciding what to say,' the nurse validates the client's feelings and encourages further discussion. Option A is incorrect as it suggests withholding information unless asked, which may not align with ethical principles of honesty and transparency in relationships. Option B, while acknowledging the client's autonomy, does not provide direct support or guidance. Option D is inappropriate as it involves dishonesty by suggesting telling the partner an untruthful reason for the illness.

4. During the evacuation of a group of clients from a medical unit due to a fire, the nurse observes an ambulatory client walking alone toward the stairway at the end of the hall. What action should the nurse take?

• A. Assign an unlicensed assistive person to transport the client via a wheelchair.
• B. Remind the client to walk carefully down the stairs until reaching a lower floor.
• C. Ask the client to help by assisting a wheelchair-bound client to a nearby elevator.
• D. Open the closest fire doors so that ambulatory clients can evacuate more rapidly.

Correct answer: B

Rationale: During the evacuation of a unit due to a fire, ambulatory clients should be evacuated via the stairway if possible and reminded to walk carefully to ensure their safety. They do not necessarily require assistance via a wheelchair. Elevators should not be used during a fire evacuation as they can pose a risk, and fire doors should be kept closed to contain the fire and smoke, preventing its spread to other areas of the building. Therefore, reminding the client to walk carefully down the stairs is the most appropriate action in this situation. Assigning an unlicensed assistive person to transport the client via a wheelchair may delay the evacuation process and put both individuals at risk. Asking the client to help by assisting a wheelchair-bound client to an elevator is not safe during a fire evacuation. Opening fire doors indiscriminately can lead to the spread of fire and smoke, endangering the clients and staff further.

5. A male client is laughing at a television program with his wife when the evening nurse enters the room. He says his foot is hurting and he would like a pain pill. How should the nurse respond?

• A. Ask him to rate his pain on a scale of 1 to 10.
• B. Encourage him to wait until bedtime so the pill can help him sleep.
• C. Attend to the acutely ill client's needs first because this client is laughing.
• D. Instruct him in the use of deep breathing exercises for pain control.

Correct answer: A

Rationale: Obtaining a subjective estimate of the pain experience by asking the client to rate his pain helps the nurse determine which pain medication should be administered and also provides a baseline for evaluating the effectiveness of the medication. Medicating for pain should not be delayed to use it as a sleep medication, so encouraging him to wait until bedtime is incorrect. Option C is judgmental and inappropriate as all clients deserve prompt attention. Option D should be used as an adjunct to pain medication, not instead of medication, so instructing him in deep breathing exercises alone is not the priority in this situation.

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