Nursing Elites

1. A client with schizophrenia is being discharged with a prescription for risperidone (Risperdal). What is the most important instruction for the nurse to provide?

• A. Stop taking 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 C: "Report any unusual muscle movements immediately." Unusual muscle movements may indicate extrapyramidal symptoms (EPS) or tardive dyskinesia, which are serious side effects of antipsychotic medications like risperidone. It is crucial to address these symptoms promptly to prevent long-term effects. Choice A is incorrect because stopping the medication suddenly can be dangerous and should only be done under medical supervision. Choice B, while important, is not the most critical instruction in this scenario. Choice D is also incorrect as the ability to drive may be affected by the medication and should be discussed with a healthcare provider.

2. A client with bipolar disorder is being discharged with a prescription for lithium. What is the most important instruction the nurse should provide?

• A. Avoid foods high in sodium.
• B. Drink plenty of fluids, especially during hot weather.
• C. Take your medication with food.
• D. Monitor your blood pressure regularly.

Correct answer: B

Rationale: The correct answer is to instruct the client to drink plenty of fluids, especially during hot weather. Maintaining adequate hydration is crucial for clients taking lithium as dehydration can lead to lithium toxicity. Choice A is incorrect because while it is important to monitor sodium intake, staying hydrated is more critical. Choice C is incorrect as lithium is usually recommended to be taken with food to reduce stomach upset. Choice D is also important but not the most crucial instruction compared to ensuring proper hydration.

3. A client who has just been sexually assaulted is calm and quiet. The nurse analyzes this behavior as indicating which defense mechanism?

• A. Denial
• B. Projection
• C. Rationalization
• D. Intellectualization

Correct answer: A

Rationale: The correct answer is A: Denial. In this situation, the client's calm and quiet demeanor after a traumatic event like sexual assault may indicate denial, a defense mechanism where the individual refuses to acknowledge the reality of the distressing event. Choice B, Projection, involves attributing one's thoughts or feelings to others. Choice C, Rationalization, is a defense mechanism where logical reasoning is used to justify behaviors or feelings. Choice D, Intellectualization, is a defense mechanism where excessive reasoning or logic is used to avoid uncomfortable emotions.

4. When caring for a client with borderline personality disorder, what is the most effective nursing intervention?

• A. Set clear and consistent boundaries for the client.
• B. Allow the client to vent their feelings without interruption.
• C. Encourage the client to participate in group therapy.
• D. Provide the client with frequent reassurance and support.

Correct answer: A

Rationale: Setting clear and consistent boundaries is essential when caring for a client with borderline personality disorder. This intervention helps provide structure, maintain a therapeutic relationship, and prevent manipulative behaviors. Allowing the client to vent feelings without interruption (Choice B) may not address the underlying issues effectively. Encouraging participation in group therapy (Choice C) can be beneficial but setting boundaries is more crucial. Providing frequent reassurance and support (Choice D) may inadvertently reinforce maladaptive behaviors instead of promoting growth and independence.

5. The LPN/LVN is caring for a client who was recently diagnosed with a mental illness. The client asks, 'Will I be able to live a normal life?' What is the best response for the nurse to provide?

• A. Yes, you will be able to live a normal life.
• B. Many people with mental illness lead full and productive lives.
• C. It will depend on your treatment and the choices you make.
• D. There is no normal; everyone is unique in their own way.

Correct answer: C

Rationale: The best response for the nurse is to provide the client with hope while acknowledging the importance of their treatment and choices. Choice C addresses the client's concern by highlighting the impact of their treatment and personal choices on their future. It encourages personal responsibility and active participation in their recovery. Choices A and B may sound reassuring, but they do not empower the client to take an active role in their well-being. Choice D, while promoting individuality, does not directly address the client's question about living a normal life after a mental illness diagnosis.

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