Nursing Elites

1. A client with Bulimia and depression who is taking phenelzine (Nardil) 90 mg daily is admitted to an acute care hospital for uncontrolled hypertension. What dietary choices should the RN instruct the client to avoid?

• A. Pan-seared catfish.
• B. Pepperoni pizza.
• C. Deep-fried shrimp.
• D. Beef strips with gravy.

Correct answer: D

Rationale: When a client is taking MAO inhibitors like phenelzine, foods containing tyramine should be avoided. Tyramine-rich foods can interact with MAO inhibitors and lead to a hypertensive crisis. Beef strips with gravy contain tyramine, making choice D the correct answer. Choices A, B, and C do not contain high levels of tyramine and are not specifically contraindicated with MAO inhibitors.

2. A male client with schizophrenia tells the RN that he is being watched and that the television is speaking directly to him. Which response by the RN is appropriate?

• A. “The television cannot speak to you.”
• B. “That sounds very frightening for you.”
• C. “You should ignore the television.”
• D. “Why do you think the television is talking to you?”

Correct answer: B

Rationale: Option B is the correct response because it acknowledges the client's feelings and demonstrates empathy. By stating that the situation sounds frightening, the RN validates the client's experience without denying or reinforcing the delusion. This approach helps build rapport and trust with the client, which is essential in therapeutic communication. Options A and C are dismissive and may invalidate the client's experience, potentially worsening the trust relationship. Option D is confrontational and may make the client defensive, hindering effective communication and rapport-building.

3. A client who refuses antipsychotic medications disrupts group activities, talks with nonsensical words, and wanders into other clients' rooms. The nurse decides that the client needs constant observation based on which of these assessment findings?

• A. Wanders into clients' rooms.
• B. Refuses antipsychotic medication.
• C. Talks with nonsensical words.
• D. Disrupts group activities.

Correct answer: D

Rationale: The correct answer is D. Disrupting group activities is a significant behavior that can pose risks to both the client and others. When combined with talking nonsensically and wandering into other clients' rooms, it indicates a need for constant observation to prevent harm or injury. Choices A, B, and C, although concerning, do not directly address the immediate safety concerns presented by disruptive behavior during group activities, which can lead to unpredictable situations and potential harm.

4. A middle-aged female client with no previous psychiatric history is seen in the mental health clinic because her family describes her as having paranoid thoughts. On assessment, she tells the nurse, “I want to find out why these people are stalking me.” Which response should the nurse provide?

• A. It sounds like this experience is frightening for you.
• B. What makes you think people are stalking you?
• C. I know you are frightened, but no one is stalking you.
• D. Do you think someone is trying to harm you?

Correct answer: A

Rationale: The correct response for the nurse to provide is option A: 'It sounds like this experience is frightening for you.' This response acknowledges the client's feelings and emotions without directly challenging the delusion of being stalked. Option B is incorrect as it directly questions the client's belief, which can lead to increased defensiveness. Option C is incorrect as it denies the client's belief without addressing the underlying fear and can cause the client to feel misunderstood. Option D is incorrect as it directly asks about harm, which may not be the primary concern of the client at this moment.

5. A client who has agoraphobia (a fear of crowds) is beginning desensitization with the therapist, and the RN is reinforcing the process. Which intervention has the highest priority for this client’s plan of care?

• A. Encourage substitution of positive thoughts for negative ones.
• B. Establish trust by providing a calm, safe environment.
• C. Progressively expose the client to larger crowds.
• D. Encourage deep breathing when anxiety escalates in a crowd.

Correct answer: B

Rationale: Establishing trust and providing a calm, safe environment is crucial when working with clients with agoraphobia undergoing desensitization therapy. This approach helps build a foundation of safety and security, allowing the client to feel more comfortable and supported during the exposure process. Encouraging positive thoughts (choice A) is important, but ensuring a safe environment takes precedence. Progressively exposing the client to larger crowds (choice C) should be done gradually and in a controlled manner; rushing this process can be overwhelming and counterproductive. Encouraging deep breathing (choice D) is a helpful coping mechanism, but creating a safe and trusting environment is the initial priority to facilitate successful desensitization therapy.

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