Nursing Elites

1. The nurse is planning care for a 32-year-old male client diagnosed with HIV infection who has a history of chronic depression. Recently, the client's viral load has begun to increase rather than decrease despite his adherence to the HIV drug regimen. What should the nurse do first while taking the client's history upon admission to the hospital?

• A. Determine if the client attends a support group weekly.
• B. Hold all antidepressant medications until further notice.
• C. Ask the client if he takes St. John's Wort routinely.
• D. Have the client describe any recent changes in mood.

Correct answer: C

Rationale: The nurse's top priority upon admission is to determine if the client has been taking St. John's Wort, an herbal preparation often used for depression. St. John's Wort can interact adversely with medications used to treat HIV infection, potentially explaining the rise in the viral load (C). Asking about attending support groups (A) or recent changes in mood (D) may provide valuable information about the client's depression but is not as critical as determining St. John's Wort use. Holding antidepressant medications (B) without assessing for potential interactions can be harmful to the client.

2. A client with obsessive-compulsive disorder (OCD) repeatedly checks the locks on the doors. What is the most therapeutic nursing intervention?

• A. Allow the client to continue the behavior to reduce anxiety.
• B. Encourage the client to discuss the thoughts and feelings behind the behavior.
• C. Restrict the client's access to the locks.
• D. Schedule specific times for the client to check the locks.

Correct answer: B

Rationale: The most therapeutic nursing intervention for a client with obsessive-compulsive disorder (OCD) who repeatedly checks locks is to encourage the client to discuss the thoughts and feelings behind the behavior. By exploring the underlying anxiety and triggers, the client can work towards understanding and managing their compulsions. Choice A is incorrect because allowing the client to continue the behavior does not address the root cause or help modify the behavior. Choice C is inappropriate as restricting access to locks can increase anxiety and worsen symptoms. Choice D of scheduling specific times for checking locks does not address the underlying psychological issues driving the behavior.

3. A client with schizophrenia is being treated with risperidone (Risperdal). The nurse notices that the client has a shuffling gait and tremors. What is the nurse's priority action?

• A. Administer a PRN dose of an anticholinergic medication.
• B. Document the findings and continue to monitor the client.
• C. Assess the client's blood glucose level.
• D. Notify the healthcare provider immediately.

Correct answer: A

Rationale: A shuffling gait and tremors may indicate extrapyramidal side effects (EPS) from risperidone. The nurse's priority action should be to administer an anticholinergic medication as it can help alleviate these symptoms associated with EPS. Documenting the findings and monitoring the client (Choice B) are important but addressing the immediate symptoms takes precedence. Assessing the client's blood glucose level (Choice C) is not directly related to the observed symptoms of shuffling gait and tremors. While notifying the healthcare provider (Choice D) is important, it is not the priority action when dealing with EPS symptoms.

4. A nurse is providing discharge teaching to a client with major depressive disorder who is prescribed fluoxetine (Prozac). What is the most important teaching point for the nurse to include?

• A. You may experience dizziness, so avoid driving.
• B. It may take several weeks to feel the full effect of the medication.
• C. Avoid foods high in tyramine while taking this medication.
• D. Take this medication only when you feel depressed.

Correct answer: B

Rationale: The correct answer is B because SSRIs like fluoxetine typically take several weeks to reach their full therapeutic effect, so it's important to set realistic expectations for the client. Choice A is incorrect as dizziness is a common side effect but not the most important teaching point. Choice C is incorrect as avoiding tyramine-rich foods is more relevant for MAOIs. Choice D is incorrect as fluoxetine should be taken consistently, not only when the client feels depressed, to maintain therapeutic blood levels.

5. A 35-year-old male client on the psychiatric unit of a general hospital believes that someone is trying to poison him. The nurse understands that a client's delusions are most likely related to his

• A. early childhood experiences involving authority issues.
• B. anger about being hospitalized.
• C. low self-esteem.
• D. phobic fear of food.

Correct answer: C

Rationale: Psychotic clients often experience delusions due to difficulties with trust and low self-esteem (C). In this case, the client's belief that someone is trying to poison him is likely a manifestation of his underlying issues with trust and self-worth. Building trust and promoting positive self-esteem are essential in caring for such clients. Choices A, B, and D are incorrect because delusions are not primarily related to early childhood experiences involving authority issues, anger about hospitalization, or phobic fear of food. These factors do not directly contribute to the development of delusions in psychotic clients.

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