Nursing Elites

1. What is the most appropriate nursing intervention for a client with obsessive-compulsive disorder (OCD) who is constantly washing her hands?

• A. Allow the client to continue washing her hands.
• B. Set limits on the time spent washing her hands.
• C. Encourage the client to wash her hands less frequently.
• D. Assist the client in finding alternative ways to reduce anxiety.

Correct answer: D

Rationale: Assisting the client in finding alternative ways to reduce anxiety is the most appropriate intervention for a client with OCD who is constantly washing her hands. This approach helps address the underlying cause of the compulsive behavior by focusing on reducing anxiety rather than reinforcing the behavior. Allowing the client to continue washing her hands (choice A) would not address the root of the issue and may perpetuate the behavior. Setting limits on the time spent washing hands (choice B) may cause distress to the client and does not address the core problem. Encouraging the client to wash her hands less frequently (choice C) does not provide effective coping strategies for managing anxiety associated with OCD.

2. When preparing a teaching plan for a client who is to be discharged with a prescription for lithium carbonate (Lithonate), which instruction is most important for the nurse to include?

• A. It may take 3 to 4 weeks to achieve therapeutic effects.
• B. Keep your dietary salt intake consistent.
• C. Avoid eating aged cheese and chicken liver.
• D. Eat foods high in fiber such as whole grain breads.

Correct answer: B

Rationale: The correct answer is B: 'Keep your dietary salt intake consistent.' Consistent salt intake is crucial when taking lithium carbonate to avoid lithium toxicity or ineffectiveness due to its renal excretion mechanism. Option A is incorrect because it focuses on the time to achieve therapeutic effects, which is important but not as critical as maintaining consistent salt intake. Option C is incorrect as it mentions avoiding aged cheese and chicken liver, which is more relevant for individuals taking MAOIs. Option D is incorrect as it suggests eating high-fiber foods, which is not directly related to lithium carbonate therapy.

3. A nurse working in a psychiatric unit is assessing a client who appears to be responding to internal stimuli. The client is laughing and talking to himself. What is the nurse's best initial response?

• A. Approach the client and ask if he is hearing voices.
• B. Ignore the behavior as it is common in psychiatric settings.
• C. Encourage the client to express his thoughts verbally.
• D. Observe the client's behavior from a distance.

Correct answer: A

Rationale: Approaching the client and asking if he is hearing voices is the best initial response by the nurse. This action can help assess the situation and determine if the client is experiencing hallucinations that may require immediate intervention. Choice B is incorrect because ignoring the behavior could lead to missing important signs of distress or potential risks. Choice C may not address the immediate concern of assessing for hallucinations. Choice D is also not ideal as observing from a distance may not provide the necessary information for immediate assessment and intervention.

4. A client is on a methadone maintenance program for opioid addiction. What is the most important assessment to perform?

• A. Monitor for signs of withdrawal.
• B. Assess for signs of methadone toxicity.
• C. Evaluate the client's respiratory status.
• D. Check the client's blood pressure regularly.

Correct answer: C

Rationale: The most important assessment to perform for a client on a methadone maintenance program is to evaluate the client's respiratory status. Methadone can cause respiratory depression as a side effect, making it crucial to monitor the client's breathing to prevent potential complications. Monitoring for signs of withdrawal (choice A) is important but not the most critical in this scenario. Assessing for signs of methadone toxicity (choice B) is relevant, but respiratory status takes precedence due to the risk of respiratory depression. Checking the client's blood pressure regularly (choice D) is important for overall assessment but is not as crucial as monitoring respiratory status in this case.

5. A client with schizophrenia who has been stabilized on medication is being discharged from the hospital. What discharge teaching is most important for the LPN/LVN to reinforce?

• A. The importance of adhering to the prescribed medication regimen.
• B. How to recognize early signs of relapse.
• C. The need to continue follow-up appointments with the healthcare provider.
• D. The importance of maintaining a healthy lifestyle, including proper diet and exercise.

Correct answer: A

Rationale: The correct answer is A. Reinforcing the importance of adhering to the prescribed medication regimen is crucial for preventing relapse in clients with schizophrenia. Compliance with medication is essential in managing the symptoms and preventing a worsening of the condition. Choice B, recognizing early signs of relapse, is important but secondary to ensuring medication adherence. Choice C, follow-up appointments, is also important but not as critical as medication compliance immediately post-discharge. Choice D, maintaining a healthy lifestyle, is beneficial for overall health but is not as directly linked to preventing relapse in schizophrenia as medication adherence.

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