Nursing Elites

1. A client who is admitted with a closed head injury after a fall has a blood alcohol level (BAL) of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 hours following admission should the nurse identify as the priority?

• A. Place in a side-lying position with head of bed elevated.
• B. Administer disulfiram (Antabuse) immediately
• C. Give lorazepam (Ativan) PRN for signs of withdrawal.
• D. Provide thiamine and folate supplements as prescribed.

Correct answer: A

Rationale: Maintain the patient's airway is the priority for a client who is intoxicated and obtunded.

2. A female client, who is wearing dirty clothes and has a foul body odor, comes to the clinic reporting feeling scared because she is being stalked. What should the nurse do first?

• A. Offer the client a safe place to relax before interviewing her.
• B. Ask the client to describe why she is being stalked.
• C. Recommend that the client talk with a social worker.
• D. Assure the client that the healthcare provider will see her today.

Correct answer: A

Rationale: When a client presents with signs of distress and potential safety concerns, the priority is to provide a safe environment. Offering a safe place to relax can help the client feel secure and ready for further assessment and support. This action allows the nurse to establish rapport, ensure the client's immediate safety, and create a trusting relationship before delving into the details of the situation. Asking the client to describe why she is being stalked (Choice B) may exacerbate her distress and should come after ensuring her safety. Recommending that the client talk with a social worker (Choice C) is important but should follow immediate safety measures. Assuring the client that the healthcare provider will see her today (Choice D) is less critical than addressing her safety concerns and emotional state.

3. The nurse is assessing a client who has schizophrenia and is exhibiting symptoms of paranoia. Which behavior would the nurse most likely observe?

• A. The client is seen as unmotivated and withdrawn.
• B. The client is preoccupied with a fear of being harmed.
• C. The client displays a blunted affect and lacks emotional response.
• D. The client avoids group activities and shows decreased appetite.

Correct answer: B

Rationale: In clients with paranoia, they typically exhibit an intense fear of being harmed, persecuted, or targeted by others. This fear often dominates their thoughts and can significantly impact their daily functioning and interactions. Choice A, being unmotivated and withdrawn, is more indicative of negative symptoms of schizophrenia, such as avolition and social withdrawal. Choice C, displaying a blunted affect and lacking emotional response, is associated with flat affect, a symptom commonly seen in schizophrenia but not specific to paranoia. Choice D, avoiding group activities and showing decreased appetite, may be related to various symptoms or side effects, but it is not a defining characteristic of paranoia in schizophrenia.

4. A client with alcohol use disorder is being treated in a rehabilitation facility. Which behavior indicates that the client is making progress in recovery?

• A. Attends all scheduled therapy sessions regularly.
• B. Is participating in group therapy and sharing experiences.
• C. Completes a work-study program.
• D. Has a decreased need for psychiatric medication.

Correct answer: B

Rationale: The correct answer is B. Participation in group therapy and sharing experiences is a positive sign of progress in recovery for a client with alcohol use disorder. It fosters peer support, allows for personal insight, and encourages social interaction, which are essential aspects of the recovery process. Attending all scheduled therapy sessions regularly (Choice A) is important but may not necessarily indicate the same level of progress as active participation in group therapy. Completing a work-study program (Choice C) is not directly related to the client's recovery from alcohol use disorder. Having a decreased need for psychiatric medication (Choice D) is not necessarily a reliable indicator of progress in recovery from alcohol use disorder, as medication management is a separate aspect of treatment.

5. A client who has a history of bipolar disorder is recovering from a manic episode and is now experiencing depressive symptoms. Which action should the nurse take first?

• A. Assess the client for suicidal ideation.
• B. Provide a detailed schedule of daily activities.
• C. Discuss the importance of medication adherence.
• D. Encourage the client to engage in group therapy.

Correct answer: A

Rationale: Assessing for suicidal ideation is the priority when a client with bipolar disorder is transitioning from a manic episode to a depressive phase. Suicidal ideation is a critical concern during depressive episodes, and ensuring the client's safety is the top priority. Providing a detailed schedule of daily activities (Choice B) may be helpful but is not the immediate priority over assessing for suicidal ideation. Discussing the importance of medication adherence (Choice C) and encouraging group therapy (Choice D) are essential components of care but are secondary to ensuring the client's safety in the context of potential suicidal ideation.

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