Nursing Elites

1. A male client with alcohol use disorder is admitted for detoxification. The nurse knows that which symptom is a sign of severe alcohol withdrawal?

• A. Bradycardia
• B. Seizures
• C. Hyperglycemia
• D. Constipation

Correct answer: B

Rationale: Seizures are a sign of severe alcohol withdrawal and can be life-threatening, requiring immediate medical attention. Bradycardia, hyperglycemia, and constipation are not typically associated with severe alcohol withdrawal. Bradycardia is more commonly seen in opioid withdrawal, hyperglycemia could be due to other reasons like uncontrolled diabetes, and constipation is not a typical symptom of severe alcohol withdrawal.

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 client with a diagnosis of schizophrenia is experiencing auditory hallucinations. What is the most appropriate nursing intervention?

• A. Ask the client to describe the voices and what they are saying.
• B. Tell the client that the voices are not real.
• C. Encourage the client to engage in reality-based activities.
• D. Ask the client to focus on positive thoughts instead of the voices.

Correct answer: C

Rationale: The most appropriate nursing intervention for a client with schizophrenia experiencing auditory hallucinations is to encourage them to engage in reality-based activities. This intervention helps manage auditory hallucinations by redirecting the client's focus away from the hallucinations. Choice A is not recommended as it may exacerbate the hallucinations or distress the client. Choice B is incorrect because denying the reality of the voices can invalidate the client's experiences. Choice D, asking the client to focus on positive thoughts, may not be effective in addressing the auditory hallucinations directly.

4. A client with schizophrenia is experiencing distressful thoughts secondary to paranoia. Which intervention(s) should the LPN/LVN include in the plan of care? Select one intervention that does not apply.

• A. Avoid laughing when near the client
• B. Whisper when communicating near the client
• C. Increase socialization of the client among peers
• D. Have the client sign a written release of information form

Correct answer: B

Rationale: The correct intervention for a client with schizophrenia experiencing distressful thoughts secondary to paranoia is to avoid laughing when near the client. This is important as laughter can be misinterpreted and exacerbate the client's paranoia. Whispering when communicating near the client is not an appropriate intervention as it may lead the client to think secretive or negative information is being shared about them, further fueling their paranoia. Increasing socialization among peers can help provide support and reduce feelings of isolation, while having the client sign a written release of information form is not directly related to managing paranoia and distressful thoughts.

5. What is the most important nursing intervention during the first 48 hours for a client with anorexia nervosa admitted to the hospital?

• A. Providing high-calorie, high-protein meals.
• B. Monitoring vital signs and electrolytes.
• C. Encouraging the client to talk about feelings.
• D. Observing for signs of purging.

Correct answer: B

Rationale: The most important nursing intervention during the first 48 hours for a client with anorexia nervosa is monitoring vital signs and electrolytes (B) to assess for life-threatening complications. This helps in early detection of any physiological imbalances that could lead to serious consequences. Providing high-calorie, high-protein meals (A) is important for nutritional rehabilitation but comes after ensuring the client's physical stability. Encouraging the client to talk about feelings (C) and observing for signs of purging (D) are relevant aspects of care but are not as critical as monitoring vital signs and electrolytes in the initial phase of treatment.

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