Nursing Elites

1. A client with schizophrenia is being discharged home after an extended stay in a psychiatric hospital. Which statement by the client indicates that further teaching about medication management is needed?

• A. “I will take my medication only when I feel like it.”
• B. “I need to follow up with my psychiatrist regularly.”
• C. “I will notify my healthcare provider if I experience side effects.”
• D. “I should avoid alcohol while on my medication.”

Correct answer: A

Rationale: The correct answer is A. This statement indicates a lack of understanding about medication management for schizophrenia. Medications for schizophrenia should be taken consistently as prescribed for optimal effectiveness, regardless of how the client feels. Choice B is a correct statement as regular follow-up with a psychiatrist is important for monitoring progress and adjusting treatment. Choice C demonstrates good awareness of potential side effects and the need for communication with healthcare providers. Choice D reflects appropriate knowledge as alcohol can interact with medications and may reduce their effectiveness.

2. A client with schizophrenia explains that she has 20 children and then very seriously points to the nurse and explains that she is one of them. What is the most therapeutic response for the nurse to provide?

• A. Let’s go ask another nurse if this is true.
• B. My name tag shows that I am a nurse here.
• C. I cannot possibly be one of your children.
• D. I know that you don’t have 20 children.

Correct answer: B

Rationale: Option B, 'My name tag shows that I am a nurse here,' is the most appropriate response as it provides clear and factual information to help the client differentiate between reality and delusion. By pointing out a concrete piece of evidence, the nurse can gently guide the client back to reality without directly challenging or contradicting their belief. Option A, 'Let’s go ask another nurse if this is true,' delays addressing the issue and doesn't provide immediate clarification. Option C, 'I cannot possibly be one of your children,' directly contradicts the client's statement and may increase distress. Option D, 'I know that you don’t have 20 children,' does not address the client's belief and can be perceived as dismissive.

3. The healthcare professional is developing a discharge plan for a client recovering from alcohol withdrawal. Which instruction should be included in the client’s discharge teaching?

• A. Avoid all social situations involving alcohol.
• B. Continue taking prescribed medications.
• C. Contact a support group such as Alcoholics Anonymous.
• D. Avoid using any over-the-counter medications.

Correct answer: C

Rationale: It is essential to include instructions for the client to contact a support group like Alcoholics Anonymous in their discharge teaching. Support groups play a vital role in providing ongoing support, guidance, and encouragement during the recovery process from alcohol withdrawal, helping to prevent relapse. Choice A is incorrect because avoiding all social situations involving alcohol may not be practical or sustainable in the long term. Choice B is important but is not specific to the client's alcohol recovery needs. Choice D is not the top priority compared to the importance of connecting with a support group for ongoing assistance and accountability.

4. 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.

5. A female client, who is wearing dirty clothes and has a foul body odor, comes to the clinic reporting feeling scared because she is being stalked. What should the nurse do first?

• A. Offer the client a safe place to relax before interviewing her.
• B. Ask the client to describe why she is being stalked.
• C. Recommend that the client talk with a social worker.
• D. Assure the client that the healthcare provider will see her today.

Correct answer: A

Rationale: When a client presents with signs of distress and potential safety concerns, the priority is to provide a safe environment. Offering a safe place to relax can help the client feel secure and ready for further assessment and support. This action allows the nurse to establish rapport, ensure the client's immediate safety, and create a trusting relationship before delving into the details of the situation. Asking the client to describe why she is being stalked (Choice B) may exacerbate her distress and should come after ensuring her safety. Recommending that the client talk with a social worker (Choice C) is important but should follow immediate safety measures. Assuring the client that the healthcare provider will see her today (Choice D) is less critical than addressing her safety concerns and emotional state.

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