Nursing Elites

1. A male client with bipolar disorder who began taking lithium carbonate five days ago is complaining of excessive thirst, and the nurse finds him attempting to drink water from the bathroom sink faucet. Which intervention should the nurse implement?

• A. Report the client’s serum lithium level to the healthcare provider.
• B. Encourage the client to suck on hard candy to relieve the symptoms.
• C. No action is needed since polydipsia is a common side effect.
• D. Tell the client that drinking from the faucet is not allowed.

Correct answer: B

Rationale: Encouraging the client to suck on hard candy is the appropriate intervention as it can help alleviate the sensation of excessive thirst, which is a common side effect of lithium. Reporting the client’s serum lithium level to the healthcare provider may be needed if there are signs of lithium toxicity, but the priority here is to address the immediate symptom of excessive thirst. Polydipsia, or excessive thirst, is a known side effect of lithium, but it should not be left unaddressed. Simply telling the client that drinking from the faucet is not allowed does not address the underlying issue of excessive thirst and may lead to further distress.

2. The nurse on the day shift receives report about a client with depression who was found on the floor in the morning. What intervention is best for the nurse to implement?

• A. Assist the client to get out of bed and involved in an activity.
• B. Monitor the client’s appetite and sleep patterns.
• C. Assess the client’s feelings regarding the hospital stay.
• D. Explain that staff will check on the client every 30 minutes.

Correct answer: A

Rationale: Assisting the client to engage in activities is the best intervention as it can help improve mood and prevent further decline in function. This intervention can also help the client regain a sense of control and purpose. Option B, monitoring appetite and sleep patterns, is important but not the most immediate intervention needed in this situation. Option C, assessing feelings about the hospital stay, is also important but addressing the client's physical safety and well-being should take precedence. Option D, explaining the frequency of staff checks, is not as effective in addressing the client's immediate needs for engagement and support.

3. 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.

4. The nurse is developing unit policies that will include nursing guidelines for maintaining a therapeutic milieu. Which interventions should be included when providing a therapeutic milieu in an inpatient setting?

• A. Opportunities to contribute to one's treatment plan.
• B. One-on-one dialogue sessions with the therapist.
• C. Regularly scheduled unit activities for peer interaction.
• D. Home visits to reintegrate into the family.

Correct answer: C

Rationale: The nurse is responsible for maintaining a therapeutic milieu in an inpatient setting, which involves creating a secure and structured environment that promotes client safety and offers opportunities for clients to learn healthy coping skills. Regularly scheduled unit activities for peer interaction help foster socialization, support, and a sense of community among clients. Choices A and B are valuable interventions in mental health care but do not directly relate to creating a therapeutic milieu in an inpatient setting. Choice D, home visits, would typically occur post-discharge and focus on community reintegration, rather than maintaining a therapeutic milieu within the inpatient setting.

5. 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.

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