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. A client who has agoraphobia (a fear of crowds) is starting desensitization therapy with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care?

• A. Encourage the substitution of positive thoughts for negative ones.
• B. Establish trust by providing a calm, safe environment.
• C. Gradually expose the client to larger crowds.
• D. Encourage deep breathing when anxiety escalates in a crowd.

Correct answer: B

Rationale: Establishing trust by providing a calm and safe environment is crucial for the success of desensitization therapy in clients with agoraphobia. This approach helps the client feel safe and secure, allowing them to gradually confront their fear of crowds. Encouraging positive thoughts (choice A) is beneficial but not as immediately critical as creating a safe space. Progressively exposing the client to larger crowds (choice C) should occur after trust is established and in a controlled manner. Encouraging deep breathing (choice D) is helpful, but creating a safe environment takes precedence to build a foundation for successful desensitization.

3. A teenager who has lost 20 pounds in the last three months is admitted to the hospital with hypotension and tachycardia. The client reports irregular menses and hair loss. Which intervention is most important for the nurse to include in the client plan of care?

• A. Implement behavior modification therapy.
• B. Initiate caloric and nutritional therapy.
• C. Evaluate the client for low self-esteem.
• D. Record daily weights and graph trends.

Correct answer: B

Rationale: Initiating caloric and nutritional therapy is the most important intervention for this client due to the significant weight loss and presenting symptoms of hypotension, tachycardia, irregular menses, and hair loss. This intervention aims to address the physical effects of malnutrition and support the client's overall health. Behavior modification therapy (Choice A) may be beneficial in the long term to address underlying issues, but addressing the immediate nutritional needs is a priority. Evaluating the client for low self-esteem (Choice C) is important for holistic care but addressing the physical health concerns takes precedence. Recording daily weights and graphing trends (Choice D) is essential for monitoring progress but does not address the urgent need for nutritional support in this acute situation.

4. What action is most important for the RN to implement within the first 24 hours after treatment is initiated for a homeless client who reports feeling sad and depressed and has only had 4 hours of sleep in the past 2 days?

• A. Allow the client to rest and sleep.
• B. Ensure the client attends groups addressing coping skills for dealing with depression.
• C. Begin planning for the client’s discharge.
• D. Encourage verbalization of feelings.

Correct answer: A

Rationale: A: Addressing the client’s immediate need for rest and sleep is crucial for stabilization and recovery. It is essential to prioritize the client's physical well-being and provide the opportunity for adequate rest. B: Group therapy and coping skills are important but secondary to ensuring immediate needs are met. C: Discharge planning is important but should follow stabilization of the client’s immediate needs. D: Encouraging verbalization of feelings is supportive but not as urgent as addressing basic needs like rest.

5. The RN is leading a group on the inpatient psychiatric unit. Which approach should the RN use during the working phase of group development?

• A. Establishing a rapport with group members.
• B. Clarifying the nurse’s role and clients’ responsibilities.
• C. Discussing ways to use new coping skills learned.
• D. Helping clients identify areas of problems in their lives.

Correct answer: C

Rationale: During the working phase of group development, the focus should be on discussing and applying new coping skills to promote progress. This helps group members to practice and implement the skills they have learned, leading to positive outcomes. Choices A, B, and D are not ideal during the working phase. While establishing rapport is important, it is more relevant during the initial orientation phase. Clarifying roles and responsibilities is important at the beginning of group formation, and helping clients identify areas of problem in their lives is often part of the exploration phase, not the working phase.

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