Nursing Elites

1. A female client, who is wearing dirty clothes and has a foul body odor, comes to the clinic reporting feeling scared because she is being stalked. What action is most important for the nurse to take?

• A. Assure the client that she will be seen by a healthcare provider today.
• B. Recommend that the client speaks with a social worker.
• C. Ask the client if she feels comfortable sharing why she is being stalked.
• D. Offer the client a safe place to relax before interviewing her.

Correct answer: D

Rationale: The most important action for the nurse to take in this scenario is to offer the client a safe place to relax before interviewing her. The client's disheveled appearance and foul body odor suggest she may be in distress or facing challenging circumstances. By providing her with a safe and comfortable environment to relax, the nurse can help alleviate some of her distress and establish trust. This approach is crucial as the client is already feeling scared due to being stalked, indicating underlying mental health concerns. Assuring the client that she will be seen by a healthcare provider today (choice A) may not address her immediate need for safety and comfort. Recommending she speaks with a social worker (choice B) may be beneficial later but does not address the immediate need for a safe space. Asking the client if she feels comfortable sharing why she is being stalked (choice C) is not appropriate as the priority is ensuring her safety and comfort first.

2. A client diagnosed with obsessive-compulsive disorder (OCD) engages in repetitive hand washing that lasts for several hours. Which strategy should the nurse use to manage this behavior?

• A. Encourage the client to continue the behavior to alleviate anxiety.
• B. Establish a routine schedule for hand washing.
• C. Gradually reduce the amount of time spent on the behavior.
• D. Ignore the behavior as much as possible.

Correct answer: C

Rationale: In managing obsessive-compulsive disorder (OCD), it's crucial to gradually reduce the compulsive behavior to help the client learn to manage anxiety in a structured manner. Encouraging the client to continue the behavior (Choice A) would reinforce the cycle of compulsions. While establishing a routine schedule (Choice B) may provide some structure, it doesn't address the core issue of excessive hand washing. Ignoring the behavior (Choice D) may lead to worsening symptoms and does not help the client in managing their OCD effectively.

3. A male client with schizophrenia is admitted to the mental health unit after abruptly stopping his prescription for ziprasidone (Geodon) one month ago. Which question is most important for the nurse to ask the client?

• A. Have you lost interest in activities you used to enjoy?
• B. Has your ability to think or concentrate decreased?
• C. How many consecutive hours do you sleep at night?
• D. Do you hear sounds or voices that others do not hear?

Correct answer: D

Rationale: Inquiring about hallucinations is crucial for assessing the return of psychotic symptoms due to discontinuation of antipsychotic medication. Hearing sounds or voices that others do not hear can indicate the presence of auditory hallucinations, a common symptom in schizophrenia. Choices A, B, and C are important aspects to assess in clients with schizophrenia, but in this scenario, the priority is to determine if the client is experiencing hallucinations, which can be a sign of worsening psychotic symptoms.

4. A client with major depressive disorder is prescribed lithium carbonate. Which finding should the RN report to the healthcare provider?

• A. Serum lithium level of 0.8 mEq/L
• B. Blood urea nitrogen (BUN) level of 16 mg/dL
• C. Serum sodium level of 138 mEq/L
• D. Urine output of 800 mL in 24 hours

Correct answer: B

Rationale: The correct answer is B. Elevated BUN levels may indicate renal impairment, which is crucial to report for clients on lithium due to its potential kidney effects. Option A, a serum lithium level of 0.8 mEq/L, is within the therapeutic range for lithium and does not require immediate reporting. Option C, a serum sodium level of 138 mEq/L, is within the normal range and not directly related to lithium therapy. Option D, urine output of 800 mL in 24 hours, may indicate a need for further assessment but is not the most critical finding to report compared to potential renal impairment indicated by an elevated BUN level.

5. An adolescent with a history of bipolar disorder is hospitalized during a manic episode. Which intervention is most appropriate for the nurse to include in the care plan?

• A. Encourage high levels of physical activity.
• B. Provide a quiet and structured environment.
• C. Engage the client in creative arts activities.
• D. Allow the client to make decisions about their schedule.

Correct answer: B

Rationale: During a manic episode, individuals with bipolar disorder may experience heightened energy levels, decreased need for sleep, and racing thoughts. Providing a quiet and structured environment is crucial in managing these symptoms as it helps reduce external stimuli, prevent overstimulation, and promote a sense of calmness. Encouraging high levels of physical activity may exacerbate the manic symptoms by further increasing stimulation and excitement. Engaging the client in creative arts activities might be beneficial during stable periods but may not be the most appropriate intervention during a manic episode. Allowing the client to make decisions about their schedule could potentially lead to impulsivity and poor judgment, which are common characteristics of mania.

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