Nursing Elites

1. A client with depression remains in bed most of the day, declines activities, and refuses meals. Which nursing problem has the greatest priority for this client?

• A. Loss of interest in diversional activities.
• B. Social isolation.
• C. Refusal to address nutritional needs.
• D. Low self-esteem.

Correct answer: C

Rationale: The correct answer is C: 'Refusal to address nutritional needs.' In this scenario, the client's refusal to eat and address their nutritional needs poses an immediate threat to their physical health. Without proper nutrition, the client is at risk of malnutrition and its associated complications. While addressing social isolation, low self-esteem, and loss of interest in diversional activities are important aspects of holistic care for a client with depression, ensuring proper nutrition takes precedence due to the critical impact it has on the client's physical well-being. Therefore, the priority is to address the client's refusal to eat and address their nutritional needs to prevent further deterioration of their health.

2. During the admission assessment of an underweight adolescent with depression on a psychiatric unit, the nurse finds a potassium level of 2.9 mEq/dl. Which finding requires notification to the healthcare provider?

• A. Potassium level of 2.9 mEq/dl.
• B. BP of 110/70 mmHg.
• C. WBC of 10,000 mm³.
• D. Body mass index of 21.

Correct answer: A

Rationale: A potassium level of 2.9 mEq/dl is critically low, indicating hypokalemia, which can lead to serious complications such as cardiac arrhythmias. Prompt notification to the healthcare provider is essential for immediate intervention. Choice B, a blood pressure of 110/70 mmHg, is within the normal range. Choice C, a white blood cell count of 10,000 mm³, is also within normal limits and is not a concerning finding in this context. Choice D, a body mass index of 21, may indicate being underweight but is not as urgent as addressing the critically low potassium level.

3. A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of risperidone (Risperdal). When the client walks to the nurse’s station in a literally contracted position, he states that something has made his body contort into a monster. What action should the nurse take?

• A. Medicate the client with the prescribed antipsychotic thioridazine (Mellaril).
• B. Offer the client a prescribed physical therapy hot pack for muscle spasms.
• C. Direct the client to occupational therapy to distract him from somatic complaints.
• D. Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia.

Correct answer: D

Rationale: The correct action for the nurse to take in this situation is to administer the prescribed anticholinergic benztropine (Cogentin) for dystonia. The client's symptoms of body contortion and feeling like a monster are indicative of acute dystonia, which can be a side effect of antipsychotic medications like risperidone. Benztropine can help alleviate these acute dystonic reactions. Choice A is incorrect because changing the antipsychotic medication at this point is not indicated. Choice B is not appropriate as the client's symptoms are likely due to acute dystonia rather than muscle spasms. Choice C is also not the best course of action as the client needs immediate intervention for the acute dystonic reaction.

4. A client in the emergency department presents with confusion, disorientation, and agitation after drinking alcohol. Which diagnostic test should the nurse anticipate to assess for potential complications?

• A. Complete blood count (CBC)
• B. Electrolyte panel
• C. Liver function tests
• D. Urinalysis

Correct answer: B

Rationale: The correct answer is an electrolyte panel. When a client presents with confusion, disorientation, and agitation after drinking alcohol, it indicates potential complications such as electrolyte imbalances. Monitoring electrolyte levels is crucial in these cases to detect and address abnormalities that may result from alcohol intake. While a complete blood count (choice A) may provide some valuable information, it is not the primary test to assess for alcohol-related complications presenting with these symptoms. Liver function tests (choice C) are more specific for assessing liver damage due to chronic alcohol use rather than immediate complications. Urinalysis (choice D) may help detect some issues but is not the most appropriate initial test to assess for potential complications in this scenario.

5. Kyle, a patient with schizophrenia, began taking the first-generation antipsychotic haloperidol (Haldol) last week. One day you find him sitting very stiffly and not moving. He is diaphoretic, and when you ask if he is okay, he seems unable to respond verbally. His vital signs are: BP 170/100, P 110, T 104.2°F. What is the priority nursing intervention? Select all that apply.

• A. Hold his medication and contact his prescriber.
• B. Wipe him with a washcloth wet with cold water or alcohol.
• C. Administer a medication such as benztropine IM to correct this dystonic reaction.
• D. Reassure him that although there is no treatment for his tardive dyskinesia, it will pass.

Correct answer: C

Rationale: The correct intervention is to administer a medication such as benztropine IM to correct this dystonic reaction. The presentation of stiffness, diaphoresis, inability to respond verbally, and vital sign changes suggest an acute dystonic reaction, which is an extrapyramidal side effect of antipsychotic medications like haloperidol. Benztropine is an anticholinergic medication commonly used to manage these acute dystonic reactions. Option A is incorrect because holding the medication without addressing the acute symptoms may lead to worsening of the condition. Option B is incorrect as wiping with cold water or alcohol does not address the underlying cause of the symptoms. Option D is incorrect because it mentions tardive dyskinesia, which is a different condition characterized by involuntary movements that occur with long-term antipsychotic use, not the acute dystonic reaction seen here.

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