Nursing Elites

1. A female client with borderline personality disorder expresses fear of being abandoned by the nursing staff. What is the best nursing intervention?

• A. Reassure the client that she will not be abandoned.
• B. Set limits on the client's behavior and enforce them consistently.
• C. Encourage the client to talk about her fears.
• D. Rotate the nursing staff assigned to the client frequently.

Correct answer: B

Rationale: The best nursing intervention for a client with borderline personality disorder expressing fear of abandonment is to set limits on the client's behavior and enforce them consistently. This approach helps establish boundaries and provides a sense of security for the client. Choice A may provide temporary reassurance but does not address the core issue or help the client develop coping strategies. Choice C is important but should be accompanied by setting limits to address the underlying fear of abandonment. Choice D of rotating staff frequently can exacerbate the client's fear of abandonment by reinforcing the idea of being left.

2. The LPN/LVN is caring for a client who has been prescribed lithium carbonate. What is the most important instruction for the nurse to provide?

• A. Take the medication with food to avoid stomach upset.
• B. Do not change your salt intake while on this medication.
• C. Drink plenty of water and maintain a consistent salt intake.
• D. Avoid excessive intake of caffeine while on this medication.

Correct answer: B

Rationale: The most important instruction for a client prescribed lithium carbonate is not to change their salt intake. Alterations in sodium levels can impact lithium levels, leading to an increased risk of toxicity. Choice A is not crucial for lithium carbonate administration. While hydration is essential, maintaining a consistent salt intake is more critical than just increasing water intake (Choice C). Although caffeine can interact with lithium, it is not as important as maintaining a consistent salt intake (Choice D).

3. A client with panic disorder is prescribed sertraline (Zoloft). What is the most important information for the nurse to provide?

• A. You should take this medication at the same time every day.
• B. It may take several weeks for you to feel the full effect.
• C. This medication may cause a significant increase in appetite.
• D. You may experience dizziness, so avoid driving.

Correct answer: B

Rationale: The correct answer is B. SSRIs like sertraline may take several weeks to reach their full therapeutic effect, so it's important to inform the client to be patient with the treatment. Choice A is not the most crucial information regarding sertraline. Choice C is not a common side effect of sertraline. Choice D is important but not as crucial as informing about the delayed onset of action.

4. A LPN/LVN is performing a follow-up teaching session with a client discharged 1 month ago. The client is taking fluoxetine (Prozac). What information would be important for the nurse to obtain during this client visit regarding the side effects of the medication?

• A. Cardiovascular symptoms
• B. Gastrointestinal dysfunctions
• C. Problems with mouth dryness
• D. Problems with excessive sweating

Correct answer: B

Rationale: The correct answer is B: 'Gastrointestinal dysfunctions.' Fluoxetine commonly causes gastrointestinal side effects such as nausea, diarrhea, or constipation. These symptoms can significantly impact the client's quality of life and adherence to the medication regimen. Monitoring gastrointestinal issues is crucial for the nurse to ensure the client's well-being and optimize treatment outcomes. Choices A, C, and D are incorrect because cardiovascular symptoms, problems with mouth dryness, and problems with excessive sweating are not typically associated with fluoxetine use and are less likely to be a focus of concern during this client visit.

5. A female client is admitted to the psychiatric unit with a diagnosis of anorexia nervosa. What is the priority nursing intervention?

• A. Monitor the client's vital signs regularly.
• B. Encourage the client to participate in group therapy.
• C. Offer the client frequent, high-calorie snacks.
• D. Weigh the client daily at the same time.

Correct answer: D

Rationale: The correct answer is to weigh the client daily at the same time. Daily weights are crucial in monitoring the client's nutritional status and guiding treatment for weight restoration in anorexia nervosa. Monitoring vital signs is important but weighing the client daily takes precedence in this situation. Encouraging group therapy and offering high-calorie snacks are important aspects of treatment but do not take priority over monitoring the client's weight.

Similar Questions