Nursing Elites

1. A 46-year-old female client has been on antipsychotic neuroleptic medication for the past three days. She has had a decrease in psychotic behavior and appears to be responding well to the medication. On the fourth day, the client's blood pressure increases, she becomes pale and febrile, and demonstrates muscular rigidity. Which action will the nurse initiate?

• A. Place the client on seizure precautions and monitor closely.
• B. Immediately transfer the client to the ICU.
• C. Report the symptoms to the charge nurse and document in the client's chart.
• D. No action is required at this time as these are known side effects of such medications.

Correct answer: B

Rationale: These symptoms are indicative of neuroleptic malignant syndrome (NMS), which is a severe and life-threatening reaction to neuroleptic drugs. The major symptoms include fever, rigidity, autonomic instability, and encephalopathy. Respiratory failure, cardiovascular collapse, arrhythmias, and/or renal failure can lead to death. This is an emergency situation requiring immediate critical care, thus the correct action is to transfer the client to the ICU (B). Seizure precautions (A) are not relevant in this scenario. Merely describing the symptoms to the charge nurse and documenting them (C) or taking no action assuming these are common side effects (D) fail to address the critical nature of the situation and the urgency of immediate intervention.

2. The nurse asks a female client with borderline personality disorder, 'How do you feel about your children not coming to visit this weekend?' The client looks out the window and replies, 'I really don't care.' Which response is best for the nurse to provide?

• A. I noticed you were looking out the window when discussing your feelings.
• B. I think you're lying and it bothers you that your children aren't coming.
• C. I think you should discuss your children not coming in the group meeting.
• D. Why do you think your children didn't want to come visit you this weekend?

Correct answer: A

Rationale: Acknowledging the client's non-verbal behavior, such as looking out the window, demonstrates active listening and provides the client with an opportunity to explore their feelings further. Choice B is incorrect as it accuses the client of lying without any evidence, which can damage the therapeutic relationship. Choice C is inappropriate as it dismisses the client's feelings and suggests a group discussion without addressing the client's emotions directly. Choice D is also incorrect as it focuses on the children's actions rather than the client's feelings, missing an opportunity for therapeutic communication.

3. An adult male client who was admitted to the mental health unit yesterday tells the nurse that microchips were planted in his head for military surveillance of his every move. Which response is best for the nurse to provide?

• A. You are in the hospital, and I am the nurse caring for you
• B. It must be difficult for you to control your anxious feelings
• C. Go to occupational therapy and start a project
• D. You are not in a war area now; this is the United States

Correct answer: C

Rationale: Delusions often generate fear and isolation, so the nurse should help the client participate in activities that avoid focusing on the false belief and encourage interaction with others.

4. A client with bipolar disorder is experiencing a manic episode. Which nursing intervention is most appropriate?

• A. Encourage group activities to decrease isolation.
• B. Provide a structured environment with routine activities.
• C. Limit the client's physical activity to prevent exhaustion.
• D. Allow the client to choose activities freely.

Correct answer: B

Rationale: During a manic episode, individuals with bipolar disorder may exhibit excessive energy, impulsivity, and disorganized behavior. Providing a structured environment with routine activities is the most appropriate nursing intervention. This approach can help regulate the client's behavior, reduce impulsivity, and prevent engaging in potentially harmful activities. Encouraging group activities (Choice A) may exacerbate the client's symptoms due to overstimulation. Limiting physical activity (Choice C) may not address the need for structure and routine during a manic episode. Allowing the client to choose activities freely (Choice D) can lead to impulsive decision-making and may not provide the necessary boundaries required to manage the manic symptoms effectively.

5. A male client with alcohol dependence is admitted for detoxification. The nurse knows that which assessment finding is indicative of alcohol withdrawal?

• A. Bradycardia
• B. Hypotension
• C. Tremors
• D. Hyperglycemia

Correct answer: C

Rationale: Tremors are a common sign of alcohol withdrawal. The central nervous system becomes hyperexcitable due to the suppression caused by chronic alcohol intake. Tremors are a manifestation of this hyperexcitability and are a key indicator of alcohol withdrawal. Bradycardia and hypotension are more commonly associated with conditions like shock or severe dehydration rather than alcohol withdrawal. Hyperglycemia is not a typical finding in alcohol withdrawal; instead, hypoglycemia is more commonly seen due to the effects of alcohol on glucose metabolism.

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