Nursing Elites

1. In observing a client who is pacing, agitated, and presenting aggressive gestures, with rapid speech pattern and belligerent affect, what is the immediate priority of care for the nurse?

• A. Provide safety for the client and other clients on the unit
• B. Provide the clients on the unit with a sense of comfort and safety
• C. Assist the staff in caring for the client in a controlled environment
• D. Offer the client a less stimulated area to calm down and gain control

Correct answer: A

Rationale: In a situation where a client is displaying aggression and agitation, the immediate priority of care for the nurse is to ensure safety for the client and others on the unit. Providing a safe environment and implementing calming measures take precedence over other interventions. Option A is the correct choice as it addresses the crucial need for safety in a potentially volatile situation. Options B, C, and D, although important, do not address the primary concern of ensuring safety for all individuals involved.

2. A nurse notes that a depressed female client has been more withdrawn and less communicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client?

• A. Engage the client in non-threatening conversations.
• B. Schedule a daily conference with the social worker.
• C. Encourage the client's family to visit more often.
• D. Encourage the client to participate in group activities.

Correct answer: D

Rationale: The correct answer is to encourage the client to participate in group activities. Group activities can help improve social interaction and potentially reduce feelings of isolation in depressed clients. Choice A, engaging the client in non-threatening conversations, may be helpful but may not address the underlying need for social interaction that group activities can provide. Scheduling a daily conference with the social worker (Choice B) may not directly address the client's need for social engagement. Encouraging the client's family to visit more often (Choice C) is important for support but may not provide the same level of social interaction as group activities.

3. A client with generalized anxiety disorder is being taught about buspirone (BuSpar) by a nurse. Which statement by the client indicates a need for further teaching?

• A. I should take this medication on an empty stomach.
• B. It may take several weeks before I feel better.
• C. This medication does not cause dependence.
• D. I can drink alcohol while taking this medication.

Correct answer: D

Rationale: The statement 'I can drink alcohol while taking this medication' (D) indicates a need for further teaching. Clients should avoid alcohol while taking buspirone because it can increase the risk of side effects such as dizziness and drowsiness. Choices A, B, and C are correct statements regarding buspirone and do not require further teaching.

4. A client with generalized anxiety disorder (GAD) is prescribed alprazolam (Xanax). What is the most important teaching point for the nurse to include?

• A. Take this medication at the first sign of anxiety.
• B. Do not stop taking this medication abruptly.
• C. You may experience weight gain while taking this medication.
• D. This medication may cause vivid dreams.

Correct answer: B

Rationale: The most important teaching point for a client prescribed alprazolam is not to stop taking the medication abruptly. Abruptly stopping alprazolam, a benzodiazepine, can lead to withdrawal symptoms. It is crucial to taper off the medication under medical supervision to prevent adverse effects. Choice A is incorrect because taking the medication at the first sign of anxiety is not the key teaching point. Choice C is incorrect because weight gain is not a common side effect of alprazolam. Choice D is incorrect because vivid dreams are not a significant concern compared to the risks of abrupt discontinuation of the medication.

5. A client who has been admitted to the psychiatric unit tells the nurse, 'My problems are so bad that no one can help me.' Which response is best for the nurse to make?

• A. How can I help?
• B. Things probably aren't as bad as they seem right now.
• C. Let's talk about what is right with your life.
• D. I hear how miserable you are, but things will get better soon.

Correct answer: A

Rationale: Offering self shows empathy and caring (A) and is the best choice provided. (B) dismisses the client's feelings and reality. (C) avoids addressing the client's concerns directly and may come across as invalidating. Although (D) starts with acknowledging the client's feelings, the second part about things getting better soon can be perceived as offering false reassurance, which is not recommended in therapeutic communication.

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