Nursing Elites

1. A male adult is admitted because of an acetaminophen (Tylenol) overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client’s discharge plan?

• A. Eat a high-carbohydrate, low-fat, low-protein diet.
• B. Do not take any over-the-counter medication.
• C. Call the crisis hotline if feeling lonely.
• D. Avoid exposure to large crowds.

Correct answer: B

Rationale: The most important information for the nurse to include in the client’s discharge plan is to not take any over-the-counter medication. This is crucial because over-the-counter medications can potentially interact with the damaged liver and worsen the condition. Choices A, C, and D are not as critical in the context of liver damage from an acetaminophen overdose. While diet is important for overall health, specifically for liver damage, avoiding over-the-counter medications takes precedence. Calling the crisis hotline for loneliness and avoiding exposure to large crowds are important considerations but are not directly related to the client's liver damage from the acetaminophen overdose.

2. 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.

3. A client is agitated and physically aggressive. What action should the RN take first?

• A. Calmly inform the client that they will be placed in seclusion if they do not calm down.
• B. Discuss with the client the reasons for their agitation and aggression.
• C. Tell the client that physical aggression is not acceptable and must stop.
• D. Seek assistance from other staff members and follow the facility’s protocol.

Correct answer: D

Rationale: In a situation where a client is agitated and physically aggressive, the priority for the RN is to ensure the safety of the client and others. Seeking assistance from other staff members is crucial as it allows for a prompt response to manage the situation effectively and according to the facility’s protocol. Choices A, B, and C do not address the immediate need for safety or involve the collaboration of other staff members, which is essential in handling aggressive behaviors in a healthcare setting.

4. April, a 10-year-old admitted to inpatient pediatric care, has been getting more and more wound up and is losing self-control in the day room. Time-out does not appear to be an effective tool for April to engage in self-reflection. April’s mother admits to putting her in time-out up to 20 times a day. The nurse recognizes that:

• A. Time-out is an important part of April's baseline discipline.
• B. Time-out is no longer an effective therapeutic measure.
• C. April enjoys time-out and acts out to get some alone time.
• D. Time-out will need to be replaced with seclusion and restraint.

Correct answer: B

Rationale: The correct answer is B: 'Time-out is no longer an effective therapeutic measure.' In this scenario, the excessive use of time-out, up to 20 times a day, indicates that it is no longer effective in helping April self-reflect and control her behavior. Constant use of time-out without achieving the desired outcome suggests the need for alternative therapeutic interventions. Choice A is incorrect because the situation described indicates that time-out is not serving its intended purpose. Choice C is also incorrect as the behavior is not driven by a desire for alone time. Choice D is incorrect and inappropriate as seclusion and restraint should only be considered as a last resort and are not indicated based on the information provided.

5. The nurse on the evening shift receives report that a client is scheduled for electroconvulsive treatment (ECT) in the morning. Which intervention should the nurse implement the evening before the scheduled ECT?

• A. Hold all bedtime medication.
• B. Keep the client NPO after midnight.
• C. Implement elopement precautions.
• D. Give the client an enema at bedtime.

Correct answer: B

Rationale: Keeping the client NPO after midnight is essential to prevent aspiration during the ECT procedure. Choice A, holding all bedtime medication, is not necessary unless specified by the healthcare provider. Choice C, implementing elopement precautions, is unrelated to preparing for ECT. Choice D, giving the client an enema at bedtime, is not a standard pre-ECT intervention.

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