Nursing Elites

1. An adolescent who attempted suicide with a drug overdose arrives in the emergency department with an empty 30-tablet bottle of acetaminophen (Tylenol). Which action should the nurse implement?

• A. Administer acetylcysteine (Mucomyst).
• B. Monitor cardiac rhythm for flat T waves.
• C. Check both serum AST and ALT levels.
• D. Prepare to administer Syrup of Ipecac.

Correct answer: A

Rationale: The correct action for the nurse to implement is to administer acetylcysteine (Mucomyst). Acetylcysteine is the antidote for acetaminophen overdose and should be administered promptly to prevent liver damage. Monitoring cardiac rhythm for flat T waves (Choice B) is not specific to acetaminophen overdose and is more related to cardiac conditions. Checking serum AST and ALT levels (Choice C) may be done later but is not the initial priority in this situation. Similarly, preparing to administer Syrup of Ipecac (Choice D) is not recommended anymore in cases of overdose as it can cause more harm.

2. A client with schizophrenia is being treated with haloperidol (Haldol). The client reports feeling restless and unable to sit still. What should the nurse do first?

• A. Instruct the client to take deep breaths and relax.
• B. Assess the client for signs of akathisia.
• C. Encourage the client to engage in physical activity.
• D. Administer a PRN dose of lorazepam (Ativan).

Correct answer: B

Rationale: Restlessness and inability to sit still are signs of akathisia, an extrapyramidal side effect of antipsychotic medications. The nurse should first assess the client for signs of akathisia by observing their movements and behavior. Assessing for akathisia is crucial to differentiate it from other conditions and to intervene appropriately. Instructing the client to relax or engage in physical activity may not address the underlying issue of akathisia. Administering lorazepam should not be the first action as it may mask the symptoms of akathisia temporarily without addressing the root cause.

3. A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to a nurse, 'I'm finally cured.' The LPN/LVN interprets this behavior as a cue to modify the treatment plan by:

• A. Suggesting a reduction of medication
• B. Allowing increased 'in-room' activities
• C. Increasing the level of suicide precautions
• D. Allowing the client off-unit privileges as needed

Correct answer: C

Rationale: A sudden improvement in mood and declaring being cured can be warning signs of a decision to attempt suicide. Therefore, the appropriate action would be to increase the level of suicide precautions to ensure the safety of the client. This can involve closer monitoring and restriction of items that could be harmful. Choices A, B, and D are incorrect as they do not address the potential risk of suicide that may be present with the sudden change in behavior.

4. The charge nurse is collaborating with the nursing staff about the plan of care for a client who is very depressed. What is the most important intervention to implement during the first 48 hours after the client's admission to the unit?

• A. Monitor appetite and observe intake during meals.
• B. Maintain safety in the client's environment.
• C. Provide ongoing, supportive contact.
• D. Encourage participation in activities.

Correct answer: B

Rationale: The most critical intervention to implement during the first 48 hours after admitting a depressed client is to maintain safety (B). Depression increases the risk of suicide; hence ensuring a safe environment is the priority. While monitoring appetite (A), providing supportive contact (C), and encouraging participation in activities (D) are important aspects of care for a depressed client, ensuring safety takes precedence in the initial phase of admission.

5. A client with obsessive-compulsive disorder (OCD) spends several hours a day washing his hands. What is the best nursing intervention?

• A. Restrict the client's access to soap and water.
• B. Encourage the client to discuss their compulsions.
• C. Allow the client to continue the behavior until ready to stop.
• D. Schedule activities that distract the client from hand-washing.

Correct answer: B

Rationale: Encouraging the client to discuss their compulsions is the best nursing intervention when caring for a client with OCD who spends excessive time on hand-washing. This approach can help the client identify underlying anxieties and triggers associated with the compulsive behavior. Restricting access to soap and water (Choice A) can lead to increased anxiety and worsen the obsession. Allowing the client to continue the behavior (Choice C) can perpetuate the compulsive cycle. Scheduling distracting activities (Choice D) may provide temporary relief but does not address the root cause of the behavior.

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