Nursing Elites

1. A male client with bipolar disorder has not slept or eaten in four days. He paces and becomes increasingly agitated and loud while the nurse talks to his spouse. What intervention is the best for the nurse to implement at this time?

• A. Move to a quiet area and provide peanut butter with crackers.
• B. Walk with the client to the cafeteria and star as he eats lunch.
• C. Request a full lunch tray from the dietary department.
• D. Encourage the spouse to eat lunch with the client.

Correct answer: A

Rationale: In this situation, the best intervention for the nurse to implement is to move the client to a quiet area and provide peanut butter with crackers. The client's behavior indicates increasing agitation and loudness, which could be exacerbated by a noisy environment. Providing a quiet space can help reduce stimuli and promote a sense of calm. Additionally, offering a small, manageable snack like peanut butter with crackers can address the client's immediate needs for sustenance without overwhelming him. Choices B, C, and D do not address the client's current agitation and lack of sleep or food effectively, making them less appropriate interventions in this scenario.

2. How should the RN respond to the mother?

• A. Ask the mother if she has ever thought about harming herself or her child.
• B. Reassure the mother that her child will achieve some growth and development milestones.
• C. Determine if the mother has other children who do not have developmental disabilities.
• D. Encourage the mother to write her thoughts and feelings in a journal.

Correct answer: A

Rationale: The correct response is to ask the mother if she has ever thought about harming herself or her child. This is crucial to assess for suicidal or homicidal thoughts, ensuring the safety of both the mother and the child. Reassuring the mother about achieving some milestones may not address her immediate emotional distress. Inquiring about other children's developmental status is not the priority when safety concerns are present. While journaling can be therapeutic, in this situation, addressing safety takes precedence.

3. The RN is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. Which strategies should be included in the safety plan? (select one that does not apply)

• A. Purchase a gun to use for protection.
• B. Keep quiet and calm.
• C. Take a self-defense course that retaliates against the abuser with injury.
• D. Have a bag ready that has extra clothes for self and children.

Correct answer: C

Rationale: Taking a self-defense course that retaliates against the abuser with injury can escalate the level of violence and is not recommended in a safety plan for a victim of intimate partner violence. The correct strategies include establishing a code, having a bag ready, and planning an escape route, which enhance safety without increasing the risk of harm.

4. During the manic phase of bipolar disorder, what is the priority nursing intervention for a female client who has not slept for the past 48 hours, is hyperactive, talkative, and engaging in risky behaviors?

• A. Encourage the client to participate in a quiet activity.
• B. Provide a safe environment and limit stimuli.
• C. Administer a sedative to help the client sleep.
• D. Discuss the consequences of her risky behaviors.

Correct answer: B

Rationale: The correct priority nursing intervention for a female client in the manic phase of bipolar disorder, who has not slept for 48 hours, is hyperactive, talkative, and engaging in risky behaviors, is to provide a safe environment and limit stimuli. This approach is crucial to prevent harm to the client and others. Encouraging a quiet activity (Choice A) may not effectively address the need for safety during the manic phase. Administering a sedative (Choice C) should be done under the guidance of a healthcare provider and does not address the immediate safety concerns. Discussing consequences of risky behaviors (Choice D) may not be effective during the manic phase when the client's judgment is impaired.

5. A LPN/LVN is performing a follow-up teaching session with a client discharged 1 month ago. The client is taking fluoxetine (Prozac). What information would be important for the nurse to obtain during this client visit regarding the side effects of the medication?

• A. Cardiovascular symptoms
• B. Gastrointestinal dysfunctions
• C. Problems with mouth dryness
• D. Problems with excessive sweating

Correct answer: B

Rationale: The correct answer is B: 'Gastrointestinal dysfunctions.' Fluoxetine commonly causes gastrointestinal side effects such as nausea, diarrhea, or constipation. These symptoms can significantly impact the client's quality of life and adherence to the medication regimen. Monitoring gastrointestinal issues is crucial for the nurse to ensure the client's well-being and optimize treatment outcomes. Choices A, C, and D are incorrect because cardiovascular symptoms, problems with mouth dryness, and problems with excessive sweating are not typically associated with fluoxetine use and are less likely to be a focus of concern during this client visit.

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