Nursing Elites

1. A client with schizophrenia is experiencing auditory hallucinations. Which of the following actions should the nurse take?

• A. Encourage the client to lie down in a quiet room.
• B. Ask the client directly what they are hearing.
• C. Tell the client that the voices are not real.
• D. Provide headphones for the client to listen to music.

Correct answer: B

Rationale: The correct action for the nurse to take when caring for a client with schizophrenia experiencing auditory hallucinations is to ask the client directly what they are hearing. This approach helps the nurse gain insight into the client's experience, establish effective communication, and provide appropriate support. Encouraging the client to lie down in a quiet room (Choice A) may not address the hallucinations directly. Telling the client that the voices are not real (Choice C) can be invalidating and may lead to further distress. Providing headphones for music (Choice D) may not be effective in addressing the client's hallucinations.

2. A client is being taught by a nurse how to ascend stairs while using crutches. Which of the following actions should the nurse instruct the client to take first?

• A. Move both crutches up first
• B. Step up with the unaffected leg first
• C. Lean forward on the crutches before stepping up
• D. Hold onto the handrail for support

Correct answer: B

Rationale: The correct answer is to instruct the client to step up with the unaffected leg first. This action is crucial as it ensures proper balance and safety when ascending stairs with crutches. By stepping up with the unaffected leg first, the client can maintain stability and reduce the risk of falls. Choices A, C, and D are incorrect. Moving both crutches up first (Choice A) may lead to imbalance and difficulty in weight distribution. Leaning forward on the crutches before stepping up (Choice C) can compromise the client's stability and increase the risk of falling. While holding onto the handrail for support (Choice D) is important, stepping up with the unaffected leg first takes precedence to establish a secure and safe movement up the stairs.

3. A nurse is providing discharge instructions to a client who has a new prescription for haloperidol. Which of the following adverse effects should the nurse instruct the client to report to the provider?

• A. Weight gain.
• B. Dry mouth.
• C. Sedation.
• D. Shuffling gait.

Correct answer: D

Rationale: The correct answer is D: Shuffling gait. A shuffling gait can indicate extrapyramidal symptoms, a potentially serious side effect of haloperidol. Extrapyramidal symptoms include movement disorders such as dystonia, akathisia, parkinsonism, and tardive dyskinesia. Reporting this symptom promptly is crucial to prevent further complications. Choices A, B, and C are common side effects of haloperidol but are not as urgent or indicative of serious complications compared to a shuffling gait.

4. A client with hypertension is asking for lifestyle changes. What should the nurse recommend?

• A. Increase sodium intake to manage blood pressure
• B. Reduce caffeine and alcohol consumption
• C. Encourage the client to increase protein intake
• D. Increase intake of fruits and vegetables

Correct answer: B

Rationale: The correct answer is B: Reduce caffeine and alcohol consumption. This recommendation is crucial for managing hypertension as excessive caffeine and alcohol intake can elevate blood pressure. By reducing these stimulants, the client can help regulate their blood pressure levels. Choices A, C, and D are incorrect. Increasing sodium intake (Choice A) is contraindicated in hypertension as it can lead to fluid retention and worsen blood pressure. Encouraging increased protein intake (Choice C) and increasing intake of fruits and vegetables (Choice D) are generally healthy dietary suggestions but not specifically targeted at managing hypertension.

5. A client with hypothyroidism may present with which of the following findings?

• A. Weight gain
• B. Hair loss
• C. Dry skin
• D. Diarrhea

Correct answer: C

Rationale: Dry skin is a common manifestation of hypothyroidism due to decreased thyroid hormone levels, leading to reduced sweating and oil production. Weight gain may occur due to a slowed metabolism, not diarrhea, as hypothyroidism is more commonly associated with constipation. Hair loss is typically associated with hyperthyroidism, not hypothyroidism.

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