Nursing Elites

1. An older female adult who lives in a nursing home is loudly demanding that the nurse call her son who has been deceased for five years. Which intervention should the nurse implement?

• A. Assist the client in making the phone call.
• B. Remind the client about her son's passing.
• C. Escort the client to a private area.
• D. Direct the client to a new activity.

Correct answer: D

Rationale: In this situation, the most appropriate intervention is to direct the client to a new activity. This approach can help redirect the client's attention, distract her from the distressing request, and engage her in a more positive interaction. Choice A could exacerbate the client's distress by attempting to make the impossible call, and reminding the client about her son's passing (Choice B) may increase her emotional distress. Escorting the client to a private area (Choice C) does not address the underlying issue and may not effectively manage the situation.

2. An elderly female client with advanced dementia is admitted to the hospital with a fractured hip. The client repeatedly tells the staff, 'Take me home. I want my Mommy.' Which response is best for the nurse to provide?

• A. Orient the client to the time, place, and person.
• B. Tell the client that the nurse is there and will help her.
• C. Remind the client that her mother is no longer living.
• D. Explain the seriousness of her injury and need for hospitalization.

Correct answer: B

Rationale: Those with dementia often refer to home or parents when seeking security and comfort. The nurse should use the techniques of 'offering self' and 'talking to the feelings' to provide reassurance (B). Clients with advanced dementia have permanent physiological changes in the brain (plaques and tangles) that prevent them from comprehending and retaining new information, so choices A, C, and D are likely to be of little use to this client and do not address the emotional needs expressed by the client. Option B acknowledges the client's feelings, offers support, and provides reassurance, which can help comfort the client during this distressing time.

3. The LPN/LVN is assessing a client who is taking an antipsychotic medication. Which of the following symptoms is uniquely indicative of neuroleptic malignant syndrome (NMS) and requires immediate attention?

• A. Very high temperature
• B. Muscular rigidity
• C. Tremors
• D. Altered consciousness

Correct answer: A

Rationale: A very high temperature is a hallmark symptom of Neuroleptic Malignant Syndrome (NMS), which is a rare but potentially life-threatening side effect of antipsychotic medications. This symptom is uniquely indicative of NMS and requires immediate medical attention. Muscular rigidity, tremors, and altered consciousness can be seen in other conditions but are not as specifically linked to NMS as a very high temperature.

4. A client with bipolar disorder is prescribed lithium. What is the most important instruction the nurse should provide?

• A. Avoid foods high in potassium while taking this medication.
• B. Take your medication with food to prevent nausea.
• C. Be sure to maintain a consistent sodium intake.
• D. You can stop taking the medication once your symptoms improve.

Correct answer: C

Rationale: Maintaining a consistent sodium intake is crucial for clients taking lithium because changes in sodium levels can impact lithium concentrations, potentially leading to toxicity. It is essential to avoid excessive sodium intake, as both low and high levels can affect lithium levels. Choices A, B, and D are incorrect. A high potassium diet is not a concern with lithium therapy. While taking lithium with food can help reduce gastrointestinal side effects, it is not the most important instruction. Finally, abruptly stopping lithium can lead to a recurrence of symptoms or a worsening of the condition, so it is vital to follow the prescribed regimen.

5. A client with a history of bipolar disorder presents to the emergency department with symptoms of mania. What is the priority nursing intervention?

• A. Administer prescribed medication to manage symptoms.
• B. Provide a calm environment with minimal stimulation.
• C. Encourage the client to express feelings and emotions.
• D. Reinforce the need for consistent medication adherence.

Correct answer: A

Rationale: Administering prescribed medication to manage symptoms is the priority intervention for a client with symptoms of mania. During a manic episode, the client may be at risk of harm to self or others due to impulsivity and poor judgment. Medication helps stabilize the client, reduce manic symptoms, and prevent further escalation. Providing a calm environment (choice B) is important but not the priority when the client's safety is at risk. Encouraging expression of feelings (choice C) and reinforcing medication adherence (choice D) are valuable aspects of care but addressing the acute symptoms of mania takes precedence to ensure the client's immediate safety and well-being.

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