Nursing Elites

1. 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.

2. An adult male client who was admitted to the mental health unit yesterday tells the nurse that microchips were planted in his head for military surveillance of his every move. Which response is best for the LPN/LVN to provide?

• A. You are in the hospital, and I am the nurse caring for you.
• B. It must be difficult for you to control your anxious feelings.
• C. Go to occupational therapy and start a project.
• D. You are not in a war area now; this is the United States.

Correct answer: A

Rationale: The best response for the LPN/LVN to provide is option A: 'You are in the hospital, and I am the nurse caring for you.' This response is effective as it grounds the client in the present reality while also acknowledging the client's feelings. It shows acceptance of the client's experience without directly challenging the delusional belief, which can help build rapport and trust. Option B focuses on anxiety rather than validating the client's experience or addressing the delusion. Option C suggests an unrelated activity that may not be helpful in this situation. Option D attempts to correct the client's belief, which is not likely to be effective in managing delusional thoughts.

3. A woman arrives in the Emergency Center and tells the nurse she thinks she has been raped. The client is sobbing and expresses disbelief that a rape could happen because the man is her best friend. After acknowledging the client's fear and anxiety, how should the nurse respond?

• A. I would be very upset and mad if my best friend did that to me.
• B. You must feel betrayed, but maybe you might have led him on?
• C. Rape is not limited to strangers and frequently occurs by someone who is known to the victim.
• D. This does not sound like rape. Did you change your mind about having sex after the fact?

Correct answer: C

Rationale: A victim of date rape or acquaintance rape is less prone to recognize what is happening because the incident usually involves persons who know each other and the dynamics are different than rape by a stranger. Choice (C) provides confrontation for the client's denial because the victim frequently knows and trusts the perpetrator. Nurses should not express personal feelings (Choice A) when dealing with victims. Choice B, suggesting that the client led on the rapist, indicates that the sexual assault was somehow the victim's fault. Choice D is judgmental and does not display compassion or establish trust between the nurse and the client.

4. For a female client with major depressive disorder reporting feelings of hopelessness and helplessness, what is the nurse's priority intervention?

• A. Encourage the client to join a support group.
• B. Refer the client for cognitive-behavioral therapy (CBT).
• C. Assess the client's risk for suicide.
• D. Suggest the client participate in daily exercise.

Correct answer: C

Rationale: The correct answer is to assess the client's risk for suicide. When a client expresses feelings of hopelessness and helplessness, it indicates a high risk of self-harm or suicide. Therefore, the priority intervention should be to assess the client's safety. Encouraging the client to join a support group (choice A) may be beneficial but not the priority at this time. Referring the client for cognitive-behavioral therapy (CBT) (choice B) and suggesting daily exercise (choice D) are important interventions in managing depression but assessing the risk for suicide takes precedence due to the immediate safety concern.

5. A client with major depressive disorder is started on fluoxetine (Prozac). What should the nurse include in the client's discharge teaching?

• A. It may take 4-6 weeks for the medication to be effective.
• B. You should take this medication at bedtime.
• C. Avoid consuming dairy products while taking this medication.
• D. You can stop taking the medication once you feel better.

Correct answer: A

Rationale: The correct answer is A: "It may take 4-6 weeks for the medication to be effective." SSRIs like fluoxetine typically take 4-6 weeks to reach their full effect, so clients should be informed to expect a gradual improvement in symptoms. Choice B is incorrect because fluoxetine is usually taken in the morning to prevent sleep disturbances. Choice C is incorrect as there is no specific need to avoid consuming dairy products while taking fluoxetine. Choice D is incorrect because clients should never stop taking antidepressants abruptly, as it can lead to withdrawal symptoms and worsening of the condition.

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