Nursing Elites

1. A client who is diagnosed with schizophrenia is admitted to the hospital. The nurse assesses the client's mental status. Which assessment finding is most characteristic of a client with schizophrenia?

• A. Mood swings.
• B. Extreme sadness.
• C. Manipulative behavior.
• D. Flat affect.

Correct answer: D

Rationale: The correct answer is D: Flat affect. Flat affect, which is a lack of emotional expression, is highly characteristic of schizophrenia. Mood swings (choice A) are more indicative of mood disorders rather than schizophrenia. Extreme sadness (choice B) could be seen in depression but is not as specific to schizophrenia. Manipulative behavior (choice C) is not a defining characteristic of schizophrenia; it may be seen in various psychiatric conditions but is not the most characteristic feature of schizophrenia.

2. When a client with major depressive disorder expresses feelings of worthlessness and hopelessness, what is the nurse's priority intervention?

• A. Encourage the client to engage in recreational activities.
• B. Suggest the client keep a journal of their thoughts and feelings.
• C. Assess the client for suicidal ideation.
• D. Provide the client with positive affirmations.

Correct answer: C

Rationale: The correct answer is to assess the client for suicidal ideation. When a client expresses feelings of worthlessness and hopelessness, it is crucial to evaluate the risk of self-harm. Encouraging recreational activities (choice A) or suggesting journaling (choice B) may be helpful interventions but assessing for suicidal ideation takes precedence due to the immediate risk of harm. Providing positive affirmations (choice D) is not the priority when safety is a concern.

3. 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.

4. A 38-year-old female client is admitted with a diagnosis of paranoid schizophrenia. When her tray is brought to her, she refuses to eat and tells the nurse, 'I know you are trying to poison me with that food.' Which response would be most appropriate for the nurse to make?

• A. 'I'll leave your tray here. I am available if you need anything else.'
• B. 'You're not being poisoned. Why do you think someone is trying to poison you?'
• C. 'No one on this unit has ever died from poisoning. You're safe here.'
• D. 'I will talk to your healthcare provider about the possibility of changing your diet.'

Correct answer: A

Rationale: Choice (A) offers support without confrontation, allowing the client to feel safe and respected. Choices (B) and (C) directly challenge the client's delusion, which can increase anxiety and distrust. Choice (D) focuses on a non-essential issue and does not address the client's immediate emotional needs.

5. The parents of a 14-year-old boy bring their son to the hospital. He is lethargic but responsive. The mother states, 'I think he took some of my pain pills.' During the initial assessment of the teenager, what information is most important for the nurse to obtain from the parents?

• A. If he has seemed depressed recently.
• B. If a drug overdose has ever occurred before.
• C. If he might have taken any other drugs.
• D. If he has a desire to quit taking drugs.

Correct answer: C

Rationale: In a situation where a teenager is brought to the hospital after possibly ingesting pills, the most crucial information for the nurse to obtain from the parents is whether the teenager might have taken any other drugs (C). This knowledge is vital for guiding further treatment, such as administering antagonists, making it the top priority. While information about depression (A) and previous drug overdoses (B) is valuable for treatment planning, it is not as critical as knowing all substances taken. Asking about the teenager's desire to quit taking drugs (D) is not appropriate during the acute management of a drug overdose and does not take precedence over determining what other substances might have been ingested.

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