Nursing Elites

1. Narcan was administered to an adult client following a suicide attempt with an overdose of hydrocodone bitartrate (Vicodin). Within 15 minutes, the client is alert and oriented. In planning nursing care, which intervention has the highest priority at this time?

• A. Encourage the client to increase fluid intake.
• B. Obtain the client’s serum Vicodin level.
• C. Observe the client for further narcotic effects.
• D. Determine the client’s reason for attempting suicide.

Correct answer: C

Rationale: Observing the client for further narcotic effects is the priority at this time. It is crucial to monitor the client closely to prevent a relapse of symptoms or potential complications from the overdose. Encouraging fluid intake is important for overall health but not the priority after an overdose. Obtaining serum Vicodin levels may be needed later but does not address the immediate need to monitor for ongoing effects. Determining the reason for the suicide attempt is vital for psychological assessment but should come after ensuring the client's physical stability.

2. During an exacerbation of schizophrenia symptoms, which intervention should the nurse prioritize for a client with a history of schizophrenia?

• A. Encourage adherence to the medication regimen.
• B. Increase social interactions with peers.
• C. Provide a high-stimulation environment.
• D. Assess for safety risks related to the exacerbation.

Correct answer: D

Rationale: During an exacerbation of schizophrenia symptoms, the nurse should prioritize assessing for safety risks. This is critical because individuals with schizophrenia may experience heightened risks to themselves or others during this period. Encouraging adherence to the medication regimen (Choice A) is important but ensuring immediate safety takes precedence. Increasing social interactions with peers (Choice B) and providing a high-stimulation environment (Choice C) can potentially exacerbate symptoms and should be avoided during an exacerbation.

3. A client with a history of bipolar disorder is stabilized on a mood stabilizer and has been prescribed lamotrigine (Lamictal). Which outcome indicates that the medication is effective?

• A. Decrease in manic episodes.
• B. Improvement in depressive symptoms.
• C. Reduction in anxiety symptoms.
• D. Increased sleep duration.

Correct answer: B

Rationale: The correct answer is B: Improvement in depressive symptoms. Lamotrigine is commonly used as a mood stabilizer and is particularly effective in managing depressive symptoms in bipolar disorder. While it may also help with preventing manic episodes, its primary indication is for treating depressive symptoms. Choices A, C, and D are incorrect because lamotrigine is not specifically indicated for reducing manic episodes, anxiety symptoms, or increasing sleep duration in bipolar disorder.

4. The nurse completes an assessment of a client who is experiencing intimate partner violence (IPV). Which finding of the injuries should the nurse include in the documentation?

• A. The client’s significant other’s statement.
• B. Photographs.
• C. General description.
• D. A summary of the client’s feelings.

Correct answer: B

Rationale: In cases of intimate partner violence (IPV), documenting injuries is essential for legal and medical purposes. Photographs provide concrete and objective evidence of the injuries, leaving no room for interpretation or doubt. This visual documentation can be crucial in legal proceedings and serve as a critical component in ensuring the safety and well-being of the client. The significant other's statement (Choice A) may not accurately reflect the client's injuries and could be biased. A general description (Choice C) lacks the specificity and objectivity that photographs offer. Summarizing the client's feelings (Choice D) is important for emotional support but does not provide the concrete evidence needed in documenting IPV cases.

5. The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. What information should the nurse explore in-depth with the client based on this screening tool?

• A. Consumption, liver enzymes, gastrointestinal complaints, and bleeding.
• B. Minimizing drinking, frequently missing family events, guilt about drinking, and amount of daily intake.
• C. Cancer screening results, anger, gastritis, daily alcohol intake.
• D. Efforts to cut down, annoyance with questions, guilt, drinking as an “Eye-opener.”

Correct answer: D

Rationale: The correct answer is D. The CAGE questionnaire is a screening tool for alcohol use disorder. Each letter in CAGE represents a key question: Cutting down, Annoyance by criticisms, Guilty feelings, and Eye-openers. These questions help assess problematic drinking behaviors and can provide valuable insights into the client's alcohol consumption habits. Choices A, B, and C do not directly align with the specific areas of inquiry covered by the CAGE questionnaire, making them incorrect. Therefore, the nurse should focus on exploring the client's efforts to cut down, annoyance with questions, feelings of guilt, and the use of alcohol as an “Eye-opener” based on this screening tool.

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