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. Which client information indicates the need for the nurse to use the CAGE questionnaire during the admission interview?

• A. Reports difficulties with short-term memory since experiencing a traumatic brain injury.
• B. Client's medication history includes frequent use of antidepressants.
• C. Describes self as a social drinker who consumes alcoholic beverages daily.
• D. Medical history includes that the client was recently sexually assaulted.

Correct answer: C

Rationale: The correct answer is C. Describing oneself as a social drinker who consumes alcoholic beverages daily raises concerns about potential alcohol abuse issues. The CAGE questionnaire is a tool used to screen for alcohol use disorder. Choice A is incorrect as memory difficulties post-traumatic brain injury do not directly indicate a need for the CAGE questionnaire. Choice B is incorrect as the use of antidepressants, while important to note, does not specifically warrant the use of the CAGE questionnaire. Choice D is incorrect as a recent sexual assault, while significant, does not directly relate to the need for alcohol abuse screening using the CAGE questionnaire.

3. During the admission assessment, a female client requests that her husband be allowed to stay in the room. While interviewing the client, the nurse notes a discrepancy between the client's verbal and nonverbal communication. What action should the nurse take?

• A. Pay close attention and document the nonverbal messages
• B. Ask the client's husband to interpret the discrepancy
• C. Ignore the nonverbal behavior and focus on the client's verbal messages
• D. Integrate the verbal and nonverbal messages and interpret them as one

Correct answer: A

Rationale: Noting both verbal and nonverbal cues is crucial to fully understand the client's condition and any potential underlying issues. Verbal communication may not always align with nonverbal cues, which can provide valuable insights into the client's emotional state and concerns. By paying close attention to and documenting the nonverbal messages, the nurse can gather a more comprehensive understanding of the client's situation. Asking the client's husband to interpret the discrepancy may not be appropriate as it could lead to misinterpretation or breach of confidentiality. Ignoring the nonverbal behavior could result in missing essential cues affecting the overall assessment. Integrating both verbal and nonverbal messages helps in forming a holistic view of the client's needs and concerns, enabling better care delivery.

4. A client with schizophrenia is prescribed olanzapine (Zyprexa). What is the most important side effect for the nurse to monitor?

• A. Hypotension
• B. Weight gain
• C. Dry mouth
• D. Tachycardia

Correct answer: B

Rationale: The correct answer is B: Weight gain. Olanzapine (Zyprexa) is known to cause significant weight gain in patients. This side effect is crucial to monitor because it can lead to metabolic syndrome, diabetes, and cardiovascular issues. Monitoring the client's weight regularly and providing appropriate dietary guidance is essential. Hypotension (choice A), dry mouth (choice C), and tachycardia (choice D) are not commonly associated with olanzapine use and are not the primary side effects to monitor in this case.

5. A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to a nurse, 'I'm finally cured.' The LPN/LVN interprets this behavior as a cue to modify the treatment plan by:

• A. Suggesting a reduction of medication
• B. Allowing increased 'in-room' activities
• C. Increasing the level of suicide precautions
• D. Allowing the client off-unit privileges as needed

Correct answer: C

Rationale: A sudden improvement in mood and declaring being cured can be warning signs of a decision to attempt suicide. Therefore, the appropriate action would be to increase the level of suicide precautions to ensure the safety of the client. This can involve closer monitoring and restriction of items that could be harmful. Choices A, B, and D are incorrect as they do not address the potential risk of suicide that may be present with the sudden change in behavior.

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