Nursing Elites

1. A male client who recently lost a loved one arrives at the mental health center and tells the nurse he is no longer interested in his usual activities and has not slept for several days. Which priority nursing problem should the nurse include in this client’s plan of care?

• A. Risk for suicide
• B. Sleep deprivation
• C. Situational low self-esteem
• D. Social isolation

Correct answer: A

Rationale: The correct answer is A: Risk for suicide. Considering the client's recent loss, lack of interest in activities, and sleep disturbances, the nurse should prioritize assessing and addressing the risk for suicide. This client is displaying warning signs such as loss of interest in usual activities and sleep disturbances, which are commonly associated with suicidal ideation. B: Sleep deprivation is not the priority issue in this scenario, as the client's lack of sleep is likely a symptom of a deeper emotional struggle. C: Situational low self-esteem and D: Social isolation may be concerns for this client but do not take precedence over the immediate risk of suicide, given the presented symptoms.

2. A client with Bulimia and depression who is taking phenelzine (Nardil) 90 mg daily is admitted to an acute care hospital for uncontrolled hypertension. What dietary choices should the RN instruct the client to avoid?

• A. Pan-seared catfish.
• B. Pepperoni pizza.
• C. Deep-fried shrimp.
• D. Beef strips with gravy.

Correct answer: D

Rationale: When a client is taking MAO inhibitors like phenelzine, foods containing tyramine should be avoided. Tyramine-rich foods can interact with MAO inhibitors and lead to a hypertensive crisis. Beef strips with gravy contain tyramine, making choice D the correct answer. Choices A, B, and C do not contain high levels of tyramine and are not specifically contraindicated with MAO inhibitors.

3. A healthcare provider is evaluating a client's response to a new antianxiety medication. Which client statement indicates a positive response to the medication?

• A. “I feel more relaxed and less anxious.”
• B. “I am sleeping less and feel more energetic.”
• C. “I have not noticed any changes in my anxiety levels.”
• D. “I have more difficulty concentrating than before.”

Correct answer: A

Rationale: The correct answer is A: “I feel more relaxed and less anxious.” A positive response to antianxiety medication is characterized by reduced anxiety and increased relaxation. Choice B, which mentions sleeping less and feeling more energetic, suggests potential side effects rather than a positive response to the medication. Choice C indicates no change in anxiety levels, which is not indicative of a positive response. Choice D, mentioning difficulty concentrating, is also a sign of a negative response to antianxiety medication as it may suggest cognitive impairment.

4. A client with borderline personality disorder is admitted to the psychiatric unit. Which behavior should the nurse prioritize in the care plan?

• A. Self-harming behavior.
• B. Difficulty with interpersonal relationships.
• C. Impulsive spending and substance abuse.
• D. Inconsistent adherence to the treatment regimen.

Correct answer: A

Rationale: Self-harming behavior is the priority in the care plan for a client with borderline personality disorder. This behavior poses an immediate risk to the client's safety and requires prompt intervention. Difficulty with interpersonal relationships, impulsive spending, and substance abuse are also common in borderline personality disorder; however, self-harming behavior takes precedence due to its potential for severe harm. Inconsistent adherence to the treatment regimen, though important, is not as urgent as addressing the immediate safety concerns related to self-harm.

5. The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. What information should the nurse explore in-depth with the client based on this screening tool?

• A. Cancer screening result and gastritis daily alcohol intake.
• B. Consumption, liver enzyme gastrointestinal complaints, and bleeding.
• C. Efforts to cut down, annoyance with questions, guilt, and drinking as an eye-opener.
• D. Minimizes drinking, frequently misses family events, guilt about drinking, and amount of daily intake.

Correct answer: C

Rationale: The CAGE questionnaire focuses on the client’s self-perception and behaviors related to drinking, such as efforts to cut down and guilt.

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