Nursing Elites

1. A female client on a psychiatric unit is sweating profusely while vigorously doing push-ups and then running the length of the corridor several times before crashing into furniture in the sitting room. Picking herself up, she begins to verbally attack other clients. What intervention is most appropriate for the RN to use to manage the client’s behavior?

• A. Assist the client to a safe area to avoid injury.
• B. Establish clear and firm limits with the client.
• C. Offer medication to help calm the client down.
• D. Speak with the client in a calm, non-threatening manner.

Correct answer: A

Rationale: Assisting the client to a safe area is the most appropriate intervention in this scenario. This action helps prevent injury to the client and others while allowing for de-escalation in a controlled environment. While establishing clear and firm limits (Choice B) may be necessary in some situations, the immediate priority here is safety. Offering medication (Choice C) should not be the first response unless the situation escalates further and poses a risk to the client or others. Speaking with the client in a calm, non-threatening manner (Choice D) may not be effective when the client is in an agitated state and engaging in risky behavior.

2. An elderly client diagnosed with delirium is being treated with antipsychotic medication. Which side effect should the nurse monitor for in this client?

• A. Akathisia
• B. Hallucinations
• C. Orthostatic hypotension
• D. Drowsiness

Correct answer: C

Rationale: The correct side effect that the nurse should monitor for in an elderly client diagnosed with delirium and treated with antipsychotic medication is orthostatic hypotension. Antipsychotic medications can lead to a drop in blood pressure upon standing, particularly in elderly individuals. Akathisia (choice A) refers to a movement disorder characterized by a feeling of inner restlessness and a compelling need to be in constant motion, which can be a side effect of antipsychotic medications but is not specific to elderly clients with delirium. Hallucinations (choice B) are sensory perceptions that appear real but are created by the mind, and while they can be associated with certain conditions or medications, they are not a common side effect of antipsychotic medications in elderly clients with delirium. Drowsiness (choice D) is a general CNS depressant effect that can occur with antipsychotic medications but is not the specific side effect that the nurse should be monitoring for in this case.

3. A client with a diagnosis of schizophrenia is exhibiting negative symptoms such as anhedonia and social withdrawal. Which intervention should be a priority for the nurse?

• A. Encourage participation in group activities.
• B. Administer prescribed antipsychotic medication.
• C. Assist the client in setting realistic goals.
• D. Promote engagement in social interactions.

Correct answer: A

Rationale: Encouraging participation in group activities is a priority intervention for a client with schizophrenia exhibiting negative symptoms like anhedonia and social withdrawal. Group activities provide structured social interactions and can help the client gradually re-engage with others, potentially reducing social withdrawal and improving social skills. Administering antipsychotic medication (Choice B) is essential in managing positive symptoms of schizophrenia such as hallucinations and delusions, not negative symptoms like anhedonia and social withdrawal. While assisting the client in setting realistic goals (Choice C) is important for overall care, addressing social withdrawal and anhedonia is more immediate. Promoting engagement in social interactions (Choice D) is beneficial, but encouraging participation in group activities provides a structured and supportive environment that can specifically target the negative symptoms being exhibited.

4. A client who is known to abuse drugs is admitted to the psychiatric unit. Which medication should the nurse anticipate administering to a client who is exhibiting benzodiazepine withdrawal symptoms?

• A. Diphenhydramine (Benadryl)
• B. Perphenazine (Trilafon)
• C. Isocarboxazid (Marplan)
• D. Chlordiazepoxide (Librium)

Correct answer: D

Rationale: Chlordiazepoxide (Librium) is the correct choice for managing benzodiazepine withdrawal symptoms. Benzodiazepines are drugs that can lead to physical dependence, and abrupt discontinuation can result in withdrawal symptoms. Chlordiazepoxide, a benzodiazepine itself, is often used in a controlled manner to taper off the drug gradually and manage withdrawal symptoms effectively. Choices A, Diphenhydramine, and B, Perphenazine, are not typically used to manage benzodiazepine withdrawal. Choice C, Isocarboxazid, is a monoamine oxidase inhibitor (MAOI) used in the treatment of depression and not indicated for benzodiazepine withdrawal.

5. When developing a plan of care for a male client admitted with delirium tremens, who is dehydrated, experiencing auditory hallucinations, has a bruised, swollen tongue, and is confused, what action should the RN include to ensure the client is physiologically stable?

• A. Encourage oral fluids.
• B. Monitor vital signs.
• C. Keep the room dark.
• D. Apply ice to his tongue.

Correct answer: B

Rationale: Monitoring vital signs is the priority action to ensure the physiological stability of a client with delirium tremens. In this scenario, the client's dehydration, confusion, and other symptoms necessitate close monitoring of vital signs to assess their condition accurately. Encouraging oral fluids (Choice A) is important for hydration but does not directly assess physiological stability. Keeping the room dark (Choice C) may help with hallucinations but is not the primary intervention for physiological stability. Applying ice to the tongue (Choice D) addresses a symptom but is less critical compared to monitoring vital signs in this situation.

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