Nursing Elites

1. To evaluate the effectiveness of cognitive-behavioral techniques, which client outcomes should the nurse include in the plan of care?

• A. Relates insights into problematic relationships
• B. Demonstrates a healthy relationship with her husband
• C. Describes how the family can resolve problems
• D. Changes thought patterns related to problem-solving

Correct answer: D

Rationale: The correct answer is D. Cognitive-behavioral therapy focuses on changing thought patterns by guiding the client to engage in problem-solving strategies to address the current situation. This approach helps individuals modify negative thinking patterns and develop more adaptive ways to cope with challenges. Choices A, B, and C are incorrect because while they may be important aspects to consider in therapy, the primary focus in cognitive-behavioral therapy is on identifying and changing negative thought patterns rather than exploring relationships or family problem-solving skills.

2. A male client with schizophrenia is being discharged from the psychiatric unit after being stabilized with antipsychotic medications. What is the most important instruction to include in the discharge teaching?

• A. “You should see your psychiatrist every 6 months.”
• B. “It’s important to adhere to the medication regimen as prescribed.”
• C. “Try to avoid caffeine and alcohol completely.”
• D. “You should exercise daily to maintain a healthy lifestyle.”

Correct answer: B

Rationale: The most important instruction to include in the discharge teaching for a male client with schizophrenia who has been stabilized with antipsychotic medications is to adhere to the medication regimen as prescribed. Medication adherence is crucial in managing schizophrenia, preventing relapse, and maintaining stability. While seeing the psychiatrist regularly (Choice A) is important, adherence to medication is more critical for the client's immediate well-being. Avoiding caffeine and alcohol (Choice C) may be beneficial but is not as crucial as medication adherence. Daily exercise (Choice D) is important for overall health but is not the most critical instruction for managing schizophrenia.

3. A male client comes to the emergency center with an erection that will not resolve. The client reports that he is taking trazodone (Desyrel) for insomnia. Which information is most important for the nurse to ask this client?

• A. Have you taken any medication for erectile dysfunction?
• B. Are you experiencing any other sexual dysfunctions or problems?
• C. When was the last time you consumed alcohol?
• D. Do you have a history of angina or high blood pressure?

Correct answer: B

Rationale: In this scenario, the most important question for the nurse to ask the client is whether he is experiencing any other sexual dysfunctions or problems. This inquiry is crucial as it can help in determining if the persistent erection is a side effect of trazodone. Asking about medication for erectile dysfunction (Choice A) may not provide relevant information in this case, as the focus is on the potential side effects of trazodone. Inquiring about the last time the client consumed alcohol (Choice C) is not directly related to the situation at hand. Questioning about a history of angina or high blood pressure (Choice D) is important for overall assessment but is not as directly relevant to the immediate concern of the persistent erection potentially caused by trazodone.

4. A client who is admitted with a closed head injury after a fall has a blood alcohol level (BAL) of 0.28 (28%) and is difficult to arouse. Which intervention during the first 6 hours following admission should the nurse identify as the priority?

• A. Place in a side-lying position with head of bed elevated.
• B. Administer disulfiram (Antabuse) immediately
• C. Give lorazepam (Ativan) PRN for signs of withdrawal.
• D. Provide thiamine and folate supplements as prescribed.

Correct answer: A

Rationale: Maintain the patient's airway is the priority for a client who is intoxicated and obtunded.

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.

Similar Questions