Nursing Elites

1. While interviewing a client, the nurse takes notes to assist with accurate documentation later. Which statement is most accurate regarding note-taking during an interview?

• A. The client’s comfort level is increased when the nurse maintains eye contact while taking notes.
• B. The interview process is enhanced with note-taking, allowing the client to speak at a normal pace.
• C. Note-taking during an interview is not a legal obligation of the examining nurse.
• D. The nurse’s ability to directly observe the client’s nonverbal communication is limited with note-taking.

Correct answer: D

Rationale: During an interview, note-taking can hinder the nurse’s ability to directly observe the client's nonverbal cues such as body language, facial expressions, and tone of voice. These nonverbal cues are crucial for understanding the client's emotions, feelings, and overall communication. Therefore, it is essential for the nurse to strike a balance between note-taking for documentation purposes and actively observing the client's nonverbal communication to ensure a comprehensive assessment. Choices A, B, and C are incorrect because maintaining eye contact, enhancing the interview process with note-taking, and legal obligations of note-taking during an interview do not directly address the issue of limited observation of nonverbal communication while taking notes.

2. During admission to the psychiatric unit, a female client is extremely anxious and states that she is worried about the sun coming up the next day. What intervention is most important for the RN to implement during the admission process?

• A. Assist the client in developing alternative coping skills.
• B. Remain calm and use a matter-of-fact approach.
• C. Ask the client why she is so anxious.
• D. Administer a PRN sedative to help relieve her anxiety.

Correct answer: B

Rationale: During admission to a psychiatric unit, it is crucial for the registered nurse to remain calm and use a matter-of-fact approach when addressing a client who is extremely anxious. By staying composed and adopting a matter-of-fact demeanor, the nurse can help establish trust and promote a sense of calm in the client. This approach can also convey a sense of reassurance and stability, which can be beneficial in managing the client's anxiety. Assisting the client in developing alternative coping skills (Choice A) may be important in the long term but is not the most immediate priority during the admission process. Asking the client why she is anxious (Choice C) may not be helpful at this moment as the client may not be able to articulate the specific reasons due to her heightened anxiety. Administering a PRN sedative (Choice D) should not be the initial intervention as it does not address the underlying cause of the anxiety and should be considered only if other non-pharmacological interventions are ineffective.

3. An RN is providing education to the family of a client diagnosed with schizophrenia who is being treated with clozapine (Clozaril). The RN should instruct the family to report which symptom immediately?

• A. Sore throat
• B. Weight loss
• C. Constipation
• D. Lightheadedness

Correct answer: A

Rationale: The correct answer is A: Sore throat. Clozapine can lead to agranulocytosis, a condition characterized by a significant decrease in white blood cells. A sore throat can be an early sign of agranulocytosis, a potentially life-threatening adverse effect of clozapine. The family should report this symptom immediately to the healthcare provider for further evaluation and management. Choices B, C, and D are incorrect because weight loss, constipation, and lightheadedness are not typically associated with the serious adverse effect of agranulocytosis related to clozapine therapy.

4. When developing a plan of care for a male client admitted with delirium tremens, who is dehydrated, experiencing auditory hallucinations, has a bruised, swollen tongue, and is confused, what action should the RN include to ensure the client is physiologically stable?

• A. Encourage oral fluids.
• B. Monitor vital signs.
• C. Keep the room dark.
• D. Apply ice to his tongue.

Correct answer: B

Rationale: Monitoring vital signs is the priority action to ensure the physiological stability of a client with delirium tremens. In this scenario, the client's dehydration, confusion, and other symptoms necessitate close monitoring of vital signs to assess their condition accurately. Encouraging oral fluids (Choice A) is important for hydration but does not directly assess physiological stability. Keeping the room dark (Choice C) may help with hallucinations but is not the primary intervention for physiological stability. Applying ice to the tongue (Choice D) addresses a symptom but is less critical compared to monitoring vital signs in this situation.

5. During an exacerbation of schizophrenia symptoms, which intervention should the nurse prioritize for a client with a history of schizophrenia?

• A. Encourage adherence to the medication regimen.
• B. Increase social interactions with peers.
• C. Provide a high-stimulation environment.
• D. Assess for safety risks related to the exacerbation.

Correct answer: D

Rationale: During an exacerbation of schizophrenia symptoms, the nurse should prioritize assessing for safety risks. This is critical because individuals with schizophrenia may experience heightened risks to themselves or others during this period. Encouraging adherence to the medication regimen (Choice A) is important but ensuring immediate safety takes precedence. Increasing social interactions with peers (Choice B) and providing a high-stimulation environment (Choice C) can potentially exacerbate symptoms and should be avoided during an exacerbation.

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