Nursing Elites

1. A male client turns over a table in the dayroom of a psychiatric unit and threatens to throw a chair at another client. Which action is most important for the nurse to implement?

• A. Calmly approach the client and remove the chair from the client.
• B. Obtain staff assistance to help diffuse the escalating situation.
• C. Offer feedback about the client's behavior.
• D. Summon the hospital security guards as a 'show of force.'

Correct answer: B

Rationale: In a situation where a client is displaying aggressive behavior, the most important action for the nurse to implement is to obtain staff assistance to help diffuse the escalating situation. This approach ensures the safety of all individuals involved and prevents the situation from escalating further. Calmly approaching the client and removing the chair directly could agitate the client further and pose a risk to the nurse. Offering feedback about the client's behavior may not address the immediate safety concerns. Summoning hospital security guards as a 'show of force' should be a last resort after other de-escalation attempts have failed, as it may further provoke the client.

2. A client with schizophrenia is experiencing auditory hallucinations that command him to harm himself. What is the nurse's priority action?

• A. Ensure the client is not left alone.
• B. Document the content of the hallucinations.
• C. Administer PRN antipsychotic medication.
• D. Encourage the client to ignore the voices.

Correct answer: A

Rationale: The correct answer is to ensure the client is not left alone. When a client with schizophrenia is having auditory hallucinations that command self-harm, the priority is to ensure the client's safety. Leaving the client alone may increase the risk of self-harm. Documenting the content of the hallucinations (choice B) is important but not the priority when immediate safety is a concern. Administering PRN antipsychotic medication (choice C) may be necessary but is not the priority over ensuring the client's immediate safety. Encouraging the client to ignore the voices (choice D) is not as effective as ensuring the client's safety by being present and providing support.

3. A female client in an acute care facility has been on antipsychotic medications for the past three days. Her psychotic behaviors have decreased and she has had no adverse reactions. On the fourth day, the client's blood pressure increases, she becomes pale and febrile, and demonstrates muscular rigidity. What action should the nurse initiate?

• A. Place the client on seizure precautions and monitor her frequently.
• B. Take the client's vital signs and notify the physician immediately.
• C. Describe the symptoms to the charge nurse and document them in the client's record.
• D. No action is required at this time as these are known side effects of her medications.

Correct answer: B

Rationale: The correct action for the nurse to initiate is to take the client's vital signs and notify the physician immediately. These symptoms may indicate neuroleptic malignant syndrome, a rare but life-threatening reaction to antipsychotic medications, requiring immediate medical attention. Placing the client on seizure precautions and monitoring her frequently (Choice A) is not the most appropriate action in this situation. Describing the symptoms to the charge nurse and documenting them in the client's record (Choice C) delays prompt medical intervention. Choosing not to take any action (Choice D) is dangerous as the symptoms described suggest a serious condition that needs urgent evaluation and treatment.

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. An emergency department nurse is caring for an adult client who is a victim of family violence. Which priority instruction would be included in the discharge instructions?

• A. Information regarding shelters
• B. Instructions regarding calling the police
• C. Instructions regarding self-defense classes
• D. Explaining the importance of leaving the violent situation

Correct answer: A

Rationale: The correct answer is A: Information regarding shelters. Providing information about shelters is crucial in cases of family violence as it ensures the client has a safe place to go after discharge, prioritizing their immediate safety. Option B, instructions regarding calling the police, may be necessary but ensuring a safe place to stay is more immediate. Option C, instructions regarding self-defense classes, may not be appropriate as the priority is to ensure the client's safety rather than teaching self-defense. Option D, explaining the importance of leaving the violent situation, is relevant but providing information on immediate shelter options is the priority.

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