Nursing Elites

1. A 72-year-old female client is admitted to the psychiatric unit with a diagnosis of major depression. Which statement by the client should be of greatest concern to the nurse and require further assessment?

• A. "I will die if my cat dies."
• B. "I don't feel like eating this morning."
• C. "I just went to my friend's funeral."
• D. "Don't you have more important things to do?"

Correct answer: A

Rationale: Sometimes a client will use an analogy to describe themselves, and (A) would be an indication for conducting a suicide assessment. (B) could have a variety of etiologies, and while further assessment is indicated, this statement does not indicate potential suicide. The normal grief process differs from depression, and at this client's age, peer/cohort deaths are more frequent, so (C) would be within normal limits. (D) is an expression of low self-esteem typical of depression. Choices (B), (C), and (D) are examples of decreased energy and mood levels which would negate suicide ideation at this time.

2. A client is on a methadone maintenance program for opioid addiction. What is the most important assessment to perform?

• A. Monitor for signs of withdrawal.
• B. Assess for signs of methadone toxicity.
• C. Evaluate the client's respiratory status.
• D. Check the client's blood pressure regularly.

Correct answer: C

Rationale: The most important assessment to perform for a client on a methadone maintenance program is to evaluate the client's respiratory status. Methadone can cause respiratory depression as a side effect, making it crucial to monitor the client's breathing to prevent potential complications. Monitoring for signs of withdrawal (choice A) is important but not the most critical in this scenario. Assessing for signs of methadone toxicity (choice B) is relevant, but respiratory status takes precedence due to the risk of respiratory depression. Checking the client's blood pressure regularly (choice D) is important for overall assessment but is not as crucial as monitoring respiratory status in this case.

3. A 19-year-old female client with a diagnosis of anorexia nervosa wants to help serve dinner trays to other clients on a psychiatric unit. What action should the nurse take?

• A. Encourage the client's self-motivation by asking her to assist with other activities.
• B. Provide an alternative suggestion for the client to participate in the unit's activities.
• C. Allow the client to serve dinner trays to other clients but monitor closely for any signs of distress.
• D. Explain to the client that she needs to focus on her own recovery and cannot participate in serving dinner trays.

Correct answer: B

Rationale: Clients with anorexia should not be allowed to plan or prepare food for unit activities, as this can reinforce their perception of self-control. Allowing the client to serve dinner trays (C) may trigger distress or unhealthy behaviors. Therefore, it is best to provide an alternative suggestion for the client to participate in the unit's activities (B). Encouraging the client to assist with other activities (A) may inadvertently reinforce negative behaviors related to food. Explaining to the client that she cannot participate in serving dinner trays (D) without offering an alternative does not address the client's desire to help and may lead to feelings of rejection.

4. A client with PTSD is experiencing flashbacks and nightmares. Which intervention should the nurse implement first?

• A. Encourage the client to talk about the flashbacks.
• B. Assist the client in developing coping strategies.
• C. Discuss relaxation techniques with the client.
• D. Refer the client to a PTSD support group.

Correct answer: A

Rationale: Encouraging the client to talk about the flashbacks is the most appropriate initial intervention for a client with PTSD experiencing flashbacks and nightmares. This intervention helps the client express their feelings, thoughts, and experiences related to the trauma they are going through. It can assist in processing the traumatic events and starting the healing process. Choice B, assisting the client in developing coping strategies, is important but should come after the client has started to verbalize and process their experiences. Choice C, discussing relaxation techniques, may be beneficial later in the treatment process but may not be as effective initially as addressing the traumatic experiences. Choice D, referring the client to a PTSD support group, is also valuable but may not be as immediate as encouraging the client to talk about their flashbacks to begin the therapeutic process.

5. A client with anorexia nervosa is being treated in an inpatient unit. Which intervention is a priority for the nurse?

• A. Encourage the client to exercise to build muscle mass.
• B. Provide liquid supplements between meals.
• C. Allow the client to choose their own meals.
• D. Monitor the client's weight daily.

Correct answer: D

Rationale: Monitoring the client's weight daily is a priority intervention for a nurse caring for a client with anorexia nervosa. Weight monitoring is crucial in assessing the client's progress and adjusting treatment as necessary to prevent complications such as refeeding syndrome, electrolyte imbalances, and cardiac issues. Encouraging exercise (Choice A) can exacerbate the client's unhealthy relationship with food and body image. Providing liquid supplements (Choice B) is important but may not be the priority over monitoring weight. Allowing the client to choose their own meals (Choice C) may not be suitable initially as they may make unhealthy choices or avoid meals altogether.

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