Nursing Elites

1. 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.

2. A male client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. What intervention is best for the RN to implement?

• A. Isolate the client from the other clients.
• B. Administer a PRN sedative.
• C. Avoid recognizing the behavior.
• D. Escort the client to his room.

Correct answer: C

Rationale: The correct intervention for the RN to implement in this situation is to avoid recognizing the behavior. By not reinforcing the echolalia through recognition, the behavior is less likely to be perpetuated, and it can reduce annoyance to other clients on the unit. Isolating the client may lead to feelings of rejection and exacerbate the behavior. Administering a PRN sedative should not be the first line of intervention for echolalia, as it does not address the underlying cause. Escorting the client to his room does not actively address the behavior or provide a therapeutic response.

3. A client with an eating disorder is being treated in a behavioral health unit. Which behavior would the nurse expect to see if the client is responding positively to the treatment?

• A. Adherence to the treatment plan and increased self-care activities.
• B. Increased isolation from others.
• C. Frequent complaining about treatment procedures.
• D. Refusal to eat meals provided by the unit.

Correct answer: A

Rationale: A positive response to treatment for a client with an eating disorder is indicated by adherence to the treatment plan and an increase in self-care activities. These behaviors show that the client is actively engaging in their treatment and taking steps towards recovery. Option B, increased isolation from others, is not indicative of a positive response to treatment as it may suggest withdrawal or avoidance. Option C, frequent complaining about treatment procedures, is not a behavior that signifies a positive response; it may indicate dissatisfaction or discomfort with the treatment. Option D, refusal to eat meals provided by the unit, is also not a positive response as it could suggest continued resistance to treatment and potential worsening of symptoms.

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. The RN is admitting a male client who takes lithium carbonate (Eskalith) twice a day. Which information should the RN report to the HCP immediately?

• A. Short-term memory loss.
• B. Five-pound weight gain.
• C. Decreased affect.
• D. Nausea and vomiting.

Correct answer: D

Rationale: Nausea and vomiting are signs of potential lithium toxicity, which is a serious condition requiring immediate attention. These symptoms can indicate a dangerous level of lithium in the body that can lead to severe complications. Short-term memory loss (A), five-pound weight gain (B), and decreased affect (C) are important to monitor but are not as immediately concerning as symptoms of potential toxicity like nausea and vomiting.

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