Nursing Elites

1. During the manic phase of bipolar disorder, what is the priority nursing intervention for a female client who has not slept for the past 48 hours, is hyperactive, talkative, and engaging in risky behaviors?

• A. Encourage the client to participate in a quiet activity.
• B. Provide a safe environment and limit stimuli.
• C. Administer a sedative to help the client sleep.
• D. Discuss the consequences of her risky behaviors.

Correct answer: B

Rationale: The correct priority nursing intervention for a female client in the manic phase of bipolar disorder, who has not slept for 48 hours, is hyperactive, talkative, and engaging in risky behaviors, is to provide a safe environment and limit stimuli. This approach is crucial to prevent harm to the client and others. Encouraging a quiet activity (Choice A) may not effectively address the need for safety during the manic phase. Administering a sedative (Choice C) should be done under the guidance of a healthcare provider and does not address the immediate safety concerns. Discussing consequences of risky behaviors (Choice D) may not be effective during the manic phase when the client's judgment is impaired.

2. The LPN/LVN should include which interventions in the plan of care for a severely depressed client with neurovegetative symptoms? (select one that does not apply.)

• A. Permit rest periods as needed.
• B. Speaking slowly and simply.
• C. Place the client on suicide precautions.
• D. Limit and discourage food and fluid intake.

Correct answer: D

Rationale: For a severely depressed client with neurovegetative symptoms, the care plan should include rest, simple communication, suicide precautions, monitoring intake, and encouraging mild exercise. Limiting and discouraging food and fluid intake is not appropriate as proper nutrition and hydration are essential for overall well-being. This choice could lead to further complications and is not recommended in the care of a depressed client.

3. A female client with obsessive compulsive personality disorder is admitted to the hospital for a cardiac catheterization. The afternoon before the procedure, the client begins to keep detailed notes of the nursing care she is receiving and reports her findings to the RN at bedtime. What action should the nurse implement?

• A. Explain to the client that her behavior invades the rights of the nursing staff.
• B. Ask the client to explain why she is keeping a detailed record of her nursing care.
• C. Teach the client strategies to control her obsessive compulsive behavior.
• D. Encourage the client to express her feelings regarding the upcoming procedure.

Correct answer: D

Rationale: Encouraging the client to express her feelings can help address underlying anxieties and may reduce the need for obsessive behaviors. Choice A is incorrect because it may come across as confrontational and could escalate the situation. Choice B is not the best initial action as it focuses on the behavior rather than the client's emotions. Choice C is premature without first addressing the client's emotional needs.

4. A client diagnosed with undifferentiated schizophrenia is being discharged on aripiprazole (Abilify) 5 mg every night. When developing the teaching plan about the most common adverse effects, which of the following should the nurse include? Select one that does not apply.

• A. Headaches that will subside in a few weeks
• B. Transient mild anxiety
• C. Insomnia
• D. Torticollis

Correct answer: D

Rationale: The correct answer is D: Torticollis. Common side effects of aripiprazole include headaches, mild anxiety, and insomnia. These side effects are manageable during treatment. Torticollis is not a common adverse effect associated with aripiprazole and is more commonly seen with other medications or conditions. Therefore, the nurse should not include torticollis in the teaching plan about the most common adverse effects of aripiprazole.

5. A male employee who is assessed weekly in the employee clinic for blood pressure because of a history of hypertension tells the nurse that he is so upset with one of his co-workers that he would like to shoot him. What action should the nurse take first?

• A. Determine if the client has a weapon available for use.
• B. Inform the health care provider of the threat to harm a co-worker.
• C. Notify security of the client's intention to harm a co-worker.
• D. Have the employee escorted to a mental health facility.

Correct answer: A

Rationale: Determining if the client has access to a weapon is critical for immediate safety and to prevent potential harm.

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