Nursing Elites

1. When caring for a client with borderline personality disorder in a psychiatric unit, what is the most therapeutic nursing intervention?

• A. Set clear and consistent boundaries for the client.
• B. Allow the client to vent their feelings without interruption.
• C. Encourage the client to participate in group therapy.
• D. Provide the client with frequent reassurance and support.

Correct answer: A

Rationale: Setting clear and consistent boundaries is the most therapeutic nursing intervention when caring for a client with borderline personality disorder. This approach provides structure, promotes predictability, and helps prevent manipulative behaviors. By establishing boundaries, the nurse can maintain a safe therapeutic relationship with the client. Allowing the client to vent their feelings without interruption (Choice B) may not always be beneficial, as it could reinforce maladaptive behaviors. Encouraging participation in group therapy (Choice C) can be helpful but setting boundaries is more critical for individualized care. Providing the client with frequent reassurance and support (Choice D) may not address the underlying issues and can contribute to dependency rather than fostering independence and coping skills.

2. An older homeless client visits the psychiatric clinic to obtain a prescription renewal for alprazolam (Xanax). During the health assessment, the client complains of chest pain. Which action should the RN take first?

• A. Refer the client to the cardiology unit.
• B. Obtain the client's blood pressure.
• C. Assess the client for substance abuse.
• D. Determine if Xanax was taken recently.

Correct answer: D

Rationale: Determining if Xanax was taken recently is crucial as it helps assess whether the chest pain is related to medication use or another issue, guiding appropriate immediate care. This action can provide essential information to address the client's current complaint effectively. Referring the client to the cardiology unit (Choice A) may be premature without assessing the Xanax use first. While obtaining the client's blood pressure (Choice B) is important, it is not the priority when the client presents with chest pain and a history of taking Xanax. Assessing the client for substance abuse (Choice C) is also important but is secondary to first determining the potential link between Xanax and the chest pain.

3. A female client with schizophrenia tells the nurse that she believes her brain is controlled by the CIA. The nurse recognizes this as which type of delusion?

• A. Somatic delusion
• B. Paranoid delusion
• C. Persecutory delusion
• D. Grandiose delusion

Correct answer: C

Rationale: The correct answer is C: Persecutory delusion. Persecutory delusions involve beliefs of being conspired against, watched, or harassed by others, which is a common symptom in schizophrenia. In this scenario, the client's belief that her brain is controlled by the CIA aligns with persecutory delusions as she feels targeted or manipulated by an external entity. Choices A, B, and D are incorrect. Somatic delusions involve false beliefs about one's body functions or sensations, paranoid delusions involve irrational suspicions and mistrust of others, and grandiose delusions involve exaggerated beliefs of one's importance or abilities.

4. The community health nurse talks to a male client who has bipolar disorder. The client explains that he sleeps 4 to 5 hours a night and is working with his partner to start two new businesses and build an empire. The client stopped taking his medications several days ago. What nursing problem has the highest priority?

• A. Excessive work activity.
• B. Decreased need for sleep.
• C. Medication management.
• D. Inflated self-esteem.

Correct answer: C

Rationale: The most important nursing problem is medication management (C) because compliance with the medication regimen will help prevent hospitalization. The client is also exhibiting signs of mania, such as excessive work activity (A), decreased need for sleep (B), and inflated self-esteem (D); however, these problems do not have the priority of medication management. Managing the medications is crucial to stabilize the client's condition and prevent potential harm associated with untreated bipolar disorder.

5. A homeless person who is in the manic phase of bipolar disorder is admitted to the mental health unit. Which laboratory finding obtained on admission is most important for the nurse to report to the healthcare provider?

• A. Decreased thyroid stimulating hormone level
• B. Elevated liver function profile
• C. Increased white blood cell count
• D. Decreased hematocrit and hemoglobin levels

Correct answer: A

Rationale: The correct answer is A: Decreased thyroid stimulating hormone level. Hyperthyroidism causes an increased level of serum thyroid hormones (T3 and T4), which inhibit the release of TSH. In this case, a decreased TSH level can indicate hyperthyroidism, which can present with manic behavior. Elevated liver function profile (B) is not directly related to the manic phase of bipolar disorder. Increased white blood cell count (C) typically indicates an infection or inflammation, not directly related to the manic phase. Decreased hematocrit and hemoglobin levels (D) may suggest anemia but are not as crucial in the context of a manic phase of bipolar disorder.

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