Nursing Elites

1. A client with bipolar disorder is being discharged with a prescription for lithium. What is the most important instruction the nurse should provide?

• A. Avoid foods high in sodium.
• B. Drink plenty of fluids, especially during hot weather.
• C. Take your medication with food.
• D. Monitor your blood pressure regularly.

Correct answer: B

Rationale: The correct answer is to instruct the client to drink plenty of fluids, especially during hot weather. Maintaining adequate hydration is crucial for clients taking lithium as dehydration can lead to lithium toxicity. Choice A is incorrect because while it is important to monitor sodium intake, staying hydrated is more critical. Choice C is incorrect as lithium is usually recommended to be taken with food to reduce stomach upset. Choice D is also important but not the most crucial instruction compared to ensuring proper hydration.

2. A female client on a psychiatric unit is sweating profusely while she vigorously does push-ups and then runs the length of the corridor several times before crashing into furniture in the sitting room. Picking herself up, she begins to toss chairs aside, looking for a red one to sit in. When another client objects to the disturbance, the client shouts, 'I am the boss here. I do what I want.' Which nursing problem best supports these observations?

• A. Deficient diversional activity related to excess energy level.
• B. Risk for other-directed violence related to disruptive behavior.
• C. Risk for activity intolerance related to hyperactivity.
• D. Disturbed personal identity related to grandiosity.

Correct answer: B

Rationale: The client's disruptive and potentially harmful behavior, including tossing chairs and claiming authority, indicates a risk for other-directed violence. This behavior poses a threat to the safety of the client and others. While the client may have excess energy, the primary concern is the potential for violence, not just a lack of diversional activities (Choice A). The client's behavior is not solely due to hyperactivity leading to activity intolerance (Choice C) or grandiosity affecting personal identity (Choice D), making these options less appropriate in this context.

3. A client with obsessive-compulsive disorder (OCD) repeatedly checks the locks on the doors. What is the best nursing intervention?

• A. Encourage the client to discuss their fears.
• B. Limit the client's time for ritualistic behavior.
• C. Assist the client to complete the ritual faster.
• D. Prevent the client from engaging in the behavior.

Correct answer: A

Rationale: The best nursing intervention when dealing with a client with OCD who repeatedly checks locks is to encourage the client to discuss their fears. This approach can help the client identify underlying anxiety triggers and work towards developing alternative coping mechanisms. Choice B, limiting the client's time for ritualistic behavior, may increase anxiety and worsen symptoms by creating a sense of urgency. Choice C, assisting the client to complete the ritual faster, does not address the underlying issues and may reinforce the behavior. Choice D, preventing the client from engaging in the behavior, can lead to increased anxiety and distress for the client.

4. A client with post-traumatic stress disorder (PTSD) reports having frequent nightmares. What is the nurse's best response?

• A. Nightmares are common with PTSD and should decrease over time.
• B. Try to avoid thinking about the trauma before going to bed.
• C. Let's discuss some relaxation techniques you can use before bedtime.
• D. I will ask the healthcare provider to prescribe a sleep aid.

Correct answer: C

Rationale: The best response for the nurse is to discuss relaxation techniques with the client that can help reduce anxiety and stress before bedtime. This approach may potentially decrease the frequency of nightmares by promoting a more calming and peaceful pre-sleep routine. Choice A is incorrect because while nightmares can be common with PTSD, it is not guaranteed that they will decrease over time. Choice B is incorrect as avoiding thinking about the trauma may not address the underlying issue causing the nightmares. Choice D is incorrect as prescribing a sleep aid should be considered as a last resort after trying non-pharmacological interventions.

5. A 22-year-old male client is admitted to the emergency center following a suicide attempt. His records reveal that this is his third suicide attempt in the past two years. He is conscious, but does not respond to verbal commands for treatment. Which assessment finding should prompt the nurse to prepare the client for gastric lavage?

• A. He ingested the drug 3 hours prior to admission to the emergency center.
• B. The family reports that he took an entire bottle of acetaminophen (Tylenol).
• C. He is unresponsive to instructions and is unable to cooperate with emetic therapy.
• D. Those with repeated suicide attempts desire punishment to relieve their guilt.

Correct answer: C

Rationale: The correct answer is C because the client's unresponsiveness and inability to cooperate with emetic therapy indicate the need for gastric lavage. Gastric lavage is a procedure used to remove toxic substances from the stomach in cases where the patient is unresponsive or unable to cooperate. Choice A is incorrect as the time of ingestion alone does not indicate the need for gastric lavage. Choice B, although indicating a significant overdose, does not directly necessitate gastric lavage. Choice D is incorrect as it provides information about the possible psychological motivation for repeated suicide attempts, but it is not directly related to the immediate need for gastric lavage in this scenario.

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