Nursing Elites

1. A client with major depressive disorder is prescribed a selective serotonin reuptake inhibitor (SSRI). Which side effect should the nurse educate the client about?

• A. Hypertension.
• B. Sexual dysfunction.
• C. Increased appetite.
• D. Weight gain.

Correct answer: B

Rationale: The correct answer is B: Sexual dysfunction. Sexual dysfunction is a common side effect of SSRIs. While hypertension (A) can occur with other medications, it is not typically associated with SSRIs. Increased appetite (C) and weight gain (D) are potential side effects of some antidepressants, but sexual dysfunction is more specific to SSRIs. Therefore, the nurse should educate the client about the risk of sexual dysfunction when taking an SSRI.

2. When caring for a client who has overdosed on PCP, the nurse should be especially cautious about which of the following client behaviors?

• A. Visual hallucinations
• B. Violent behavior
• C. Bizarre behavior
• D. Loud screaming

Correct answer: B

Rationale: The correct answer is B: 'Violent behavior.' When a client has overdosed on PCP, the nurse should be particularly cautious about the manifestation of violent behavior. PCP overdose can lead to aggressive and unpredictable actions, posing a significant risk to both the client and healthcare providers. Visual hallucinations (choice A), bizarre behavior (choice C), and loud screaming (choice D) can also occur with PCP overdose, but the primary concern should be the potential for violent behavior, making it the most critical behavior to monitor and manage.

3. A client with obsessive-compulsive disorder (OCD) spends hours each day washing their hands. Which nursing intervention is most appropriate initially?

• A. Allow the client to continue the behavior to reduce anxiety.
• B. Set strict limits on the time allowed for handwashing.
• C. Distract the client with other activities.
• D. Encourage the client to participate in a support group.

Correct answer: A

Rationale: Initially, it is most appropriate to allow the client to continue the behavior to reduce anxiety (A). For clients with OCD, abruptly stopping compulsive behaviors can lead to increased anxiety and distress. Setting strict limits (B) may exacerbate anxiety at first. Distraction with other activities (C) may not address the underlying issue effectively. While support groups (D) can be beneficial, they are typically introduced after establishing trust and gradually working on reducing compulsive behaviors.

4. When a client with schizophrenia is being discharged on antipsychotic medication, what is the most important instruction the nurse should provide?

• A. Stop the medication if you start feeling better.
• B. Be aware of the potential for weight gain with this medication.
• C. Report any unusual muscle movements immediately.
• D. You can drive as soon as you feel ready.

Correct answer: C

Rationale: The correct answer is to instruct the client to report any unusual muscle movements immediately. These movements may indicate extrapyramidal symptoms (EPS) or tardive dyskinesia, which are serious side effects of antipsychotic medications that require immediate attention. Choice A is incorrect because stopping the medication without medical advice can lead to a relapse of symptoms. Choice B is important but not as critical as monitoring for EPS. Choice D is incorrect because driving readiness is not directly related to antipsychotic medication instructions.

5. A young adult male with a history of substance abuse is admitted to the psychiatric unit for detoxification. He is agitated, sweating, and reports seeing bugs crawling on the walls. What is the priority nursing intervention?

• A. Reassure the client that the bugs are not real.
• B. Administer the prescribed benzodiazepine.
• C. Place the client in a quiet, dark room.
• D. Encourage the client to express his feelings.

Correct answer: B

Rationale: The correct answer is to administer the prescribed benzodiazepine. This intervention helps manage the client's agitation and hallucinations, which are common symptoms during detoxification from substances. Reassuring the client that the bugs are not real (Choice A) may not be effective in addressing the underlying causes of the hallucinations. Placing the client in a quiet, dark room (Choice C) may help reduce sensory stimulation but does not directly address the client's symptoms. Encouraging the client to express his feelings (Choice D) is important for therapeutic communication but may not be the priority when the client is experiencing severe agitation and hallucinations.

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