Nursing Elites

1. What is the most important nursing intervention during the first 48 hours for a client with anorexia nervosa admitted to the hospital?

• A. Providing high-calorie, high-protein meals.
• B. Monitoring vital signs and electrolytes.
• C. Encouraging the client to talk about feelings.
• D. Observing for signs of purging.

Correct answer: B

Rationale: The most important nursing intervention during the first 48 hours for a client with anorexia nervosa is monitoring vital signs and electrolytes (B) to assess for life-threatening complications. This helps in early detection of any physiological imbalances that could lead to serious consequences. Providing high-calorie, high-protein meals (A) is important for nutritional rehabilitation but comes after ensuring the client's physical stability. Encouraging the client to talk about feelings (C) and observing for signs of purging (D) are relevant aspects of care but are not as critical as monitoring vital signs and electrolytes in the initial phase of treatment.

2. A male client who has been on lithium therapy for 5 years is experiencing frequent urination and increased thirst. What should the nurse's next action be?

• A. Instruct the client to increase fluid intake.
• B. Assess for signs of lithium toxicity.
• C. Suggest the client reduce salt intake.
• D. Notify the healthcare provider immediately.

Correct answer: B

Rationale: Frequent urination and increased thirst can be signs of lithium toxicity, which can lead to serious complications if not addressed promptly. Assessing for signs of lithium toxicity is crucial to determine the client's condition and prevent further harm. Instructing the client to increase fluid intake (Choice A) may worsen the situation by exacerbating lithium toxicity. Suggesting the client reduce salt intake (Choice C) is not the priority when signs of toxicity are present. Notifying the healthcare provider immediately (Choice D) is important, but the initial action should be to assess the client for signs of lithium toxicity to provide immediate care.

3. An elderly client was prescribed Ativan 1 mg three times a day to help calm her anxiety after her husband's death. The next day the client calls her daughter asking when she is picking her up to go to the graveside. The client says she has been walking up and down the driveway for the past hour waiting for her daughter. Noting the client's agitation, hyperactivity, and insistence, the daughter calls the nurse to report her mother's behavior. What should the nurse suspect?

• A. The client is manic and may need a sleeping pill
• B. The client is experiencing a medication interaction and should go to the ED
• C. The client is experiencing a paradoxical reaction to the Ativan and should stop the new medication immediately
• D. The client is overcome by grief and probably needs an antidepressant

Correct answer: C

Rationale: A paradoxical reaction to Ativan, where the drug causes opposite effects such as increased agitation and hyperactivity, should prompt immediate cessation of the medication. In this scenario, the client was prescribed Ativan to help calm her anxiety, but instead, she is displaying symptoms of increased agitation and hyperactivity, indicating a paradoxical reaction. Choice A is incorrect because the symptoms described do not align with mania. Choice B is incorrect as there is no mention of a medication interaction. Choice D is incorrect as the symptoms are more indicative of a paradoxical reaction rather than overwhelming grief.

4. A client with obsessive-compulsive disorder (OCD) is hospitalized for treatment. Which intervention is most important for the LPN/LVN to include in the client's plan of care?

• A. Allow the client to engage in compulsive behaviors as a way to reduce anxiety.
• B. Encourage the client to ignore the compulsive behaviors.
• C. Help the client to understand the purpose of compulsive behaviors.
• D. Work with the client to gradually reduce the frequency of compulsive behaviors.

Correct answer: D

Rationale: The correct intervention for a client with OCD is to work with them to gradually reduce the frequency of compulsive behaviors. This approach helps the client manage their condition effectively without causing undue distress. Allowing the client to engage in compulsive behaviors can reinforce the disorder rather than alleviate it. Encouraging the client to ignore compulsive behaviors does not address the core issue of OCD. While helping the client understand the purpose of compulsive behaviors can be beneficial, actively working to reduce these behaviors is more crucial in the treatment of OCD.

5. 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.

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