Nursing Elites

1. A client with borderline personality disorder is admitted to the psychiatric unit. Which intervention should the nurse implement to promote the client's safety?

• A. Implement a no-harm contract with the client.
• B. Monitor the client closely for signs of self-harm.
• C. Encourage the client to participate in recreational activities.
• D. Encourage the client to maintain a structured daily routine.

Correct answer: A

Rationale: When a client with borderline personality disorder is admitted to a psychiatric unit, implementing a no-harm contract is a crucial intervention to promote the client's safety. A no-harm contract is a formal agreement between the client and the healthcare provider stating that the client commits to not harm themselves or others. This intervention helps in establishing boundaries and promoting safety by enhancing communication and accountability between the client and the healthcare team. Monitoring the client closely for signs of self-harm (Choice B) is important but does not directly address promoting safety through a formal agreement. Encouraging participation in recreational activities (Choice C) and maintaining a structured daily routine (Choice D) are beneficial interventions but may not directly address the immediate safety concerns of a client with borderline personality disorder.

2. A client with schizophrenia is experiencing auditory hallucinations. Which intervention should the nurse implement to address this symptom?

• A. Encourage the client to discuss the voices.
• B. Tell the client that the voices are not real.
• C. Provide reality-based feedback to the client.
• D. Distract the client from the voices.

Correct answer: C

Rationale: When a client with schizophrenia is experiencing auditory hallucinations, providing reality-based feedback is a therapeutic intervention. This helps the client differentiate between what is real and what is not, aiding in reducing the impact of hallucinations. Encouraging the client to discuss the voices may validate the hallucinations, telling the client that the voices are not real dismisses their experience, and distracting the client may not address the underlying issue of the hallucinations.

3. What is the most appropriate intervention for a patient experiencing a panic attack?

• A. Encourage deep, slow breathing.
• B. Encourage the patient to talk about their feelings.
• C. Leave the patient alone to calm down.
• D. Engage the patient in a physical activity.

Correct answer: A

Rationale: Encouraging deep, slow breathing is the most appropriate intervention for a patient experiencing a panic attack. This technique can help the patient regulate their breathing, reduce hyperventilation, and promote relaxation, which are essential in managing the symptoms of a panic attack. Choice B, encouraging the patient to talk about their feelings, may not be effective during an acute panic attack as the focus should be on calming the patient down. Choice C, leaving the patient alone, can lead to increased feelings of fear and isolation during a panic attack. Choice D, engaging the patient in physical activity, may exacerbate symptoms as it can increase the feeling of being out of control.

4. A client is experiencing alcohol withdrawal. Which symptom should the nurse identify as a priority to address?

• A. Tremors
• B. Nausea and vomiting
• C. Increased blood pressure
• D. Insomnia

Correct answer: C

Rationale: During alcohol withdrawal, increased blood pressure is a critical symptom that requires immediate attention. Elevated blood pressure can lead to serious complications such as cardiovascular events or stroke. Monitoring and managing blood pressure in clients experiencing alcohol withdrawal is crucial to prevent adverse outcomes. Tremors, nausea and vomiting, and insomnia are common symptoms of alcohol withdrawal, but they are not as immediately life-threatening as increased blood pressure. Therefore, addressing increased blood pressure takes precedence in the management of a client experiencing alcohol withdrawal.

5. Which patient should be most carefully assessed for fluid and electrolyte imbalance among those receiving the following drugs?

• A. lithium (Eskalith)
• B. clozapine (Clozaril)
• C. diazepam (Valium)
• D. amitriptyline

Correct answer: A

Rationale: Lithium is known to cause polyuria (excessive urination) and polydipsia (excessive thirst), which can lead to fluid and electrolyte imbalances. Therefore, patients receiving lithium should be carefully monitored for signs of fluid and electrolyte disturbances to prevent any potential complications.

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