Nursing Elites

1. A nurse is assessing a client with generalized anxiety disorder (GAD) who reports difficulty concentrating and feeling restless. What is the most appropriate nursing intervention?

• A. Encourage the client to avoid caffeine.
• B. Suggest the client take up a new hobby.
• C. Teach the client deep breathing exercises.
• D. Refer the client to group therapy.

Correct answer: C

Rationale: Teaching deep breathing exercises is the most appropriate intervention for a client with generalized anxiety disorder (GAD) experiencing difficulty concentrating and restlessness. Deep breathing exercises are a proven technique to help manage anxiety symptoms, promote relaxation, and improve concentration. Encouraging the client to avoid caffeine (Choice A) may be beneficial, but it is not the most direct intervention for the reported symptoms. Suggesting the client take up a new hobby (Choice B) may be helpful for overall well-being but does not directly address the immediate symptoms. Referring the client to group therapy (Choice D) may be beneficial in the long term, but teaching deep breathing exercises is more immediate and can be easily implemented by the client in various settings.

2. A client with schizophrenia is being discharged with a prescription for risperidone (Risperdal). What is the most important information for the nurse to provide?

• A. You need to have regular blood tests while taking this medication.
• B. Report any muscle stiffness or unusual movements immediately.
• C. Avoid foods high in tyramine while taking this medication.
• D. This medication may cause weight loss.

Correct answer: B

Rationale: The correct answer is B: "Report any muscle stiffness or unusual movements immediately." This information is crucial because muscle stiffness or unusual movements may indicate extrapyramidal symptoms (EPS), a potential side effect of risperidone that requires immediate attention. Choice A is less critical as regular blood tests are important but not as urgent as identifying EPS. Choice C is irrelevant as tyramine interactions are not associated with risperidone. Choice D is incorrect as weight gain is more common than weight loss with risperidone.

3. An LPN/LVN is conducting an initial assessment on a client in crisis. When assessing the client's perception of the precipitating event that led to the crisis, the appropriate question to ask is:

• A. With whom do you live?
• B. Who is available to help you?
• C. What leads you to seek help now?
• D. What do you usually do to feel better?

Correct answer: C

Rationale: The correct question to ask when assessing a client's perception of the precipitating event that led to a crisis is 'What leads you to seek help now?' This question directly addresses the client's current situation and triggers that brought them to seek assistance. Choices A and B are more focused on the client's social support system rather than the root cause of the crisis. Choice D addresses coping mechanisms rather than the actual trigger for seeking help.

4. The LPN/LVN is caring for a client with post-traumatic stress disorder (PTSD). Which intervention is most appropriate for the nurse to implement?

• A. Encourage the client to talk about the traumatic event.
• B. Assist the client in developing coping strategies.
• C. Refer the client to a PTSD support group.
• D. Administer prescribed medications to manage symptoms.

Correct answer: B

Rationale: Assisting the client in developing coping strategies is an appropriate intervention for managing PTSD. This approach helps the client build resilience and learn how to effectively cope with symptoms. Choice A, encouraging the client to talk about the traumatic event, may not be appropriate as it can potentially re-traumatize the client. Referring the client to a PTSD support group, as in choice C, can be beneficial but may not be the most immediate intervention. Administering medications, as in choice D, is important in some cases, but focusing on coping strategies should be prioritized as a holistic approach to managing PTSD.

5. A female client on a psychiatric unit is sweating profusely while she vigorously does push-ups and then runs the length of the corridor several times before crashing into furniture in the sitting room. Picking herself up, she begins to toss chairs aside, looking for a red one to sit in. When another client objects to the disturbance, the client shouts, 'I am the boss here. I do what I want.' Which nursing problem best supports these observations?

• A. Deficient diversional activity related to excess energy level.
• B. Risk for other-directed violence related to disruptive behavior.
• C. Risk for activity intolerance related to hyperactivity.
• D. Disturbed personal identity related to grandiosity.

Correct answer: B

Rationale: The client's disruptive and potentially harmful behavior, including tossing chairs and claiming authority, indicates a risk for other-directed violence. This behavior poses a threat to the safety of the client and others. While the client may have excess energy, the primary concern is the potential for violence, not just a lack of diversional activities (Choice A). The client's behavior is not solely due to hyperactivity leading to activity intolerance (Choice C) or grandiosity affecting personal identity (Choice D), making these options less appropriate in this context.

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