Nursing Elites

1. On admission to a residential care facility, an elderly female client tells the nurse that she enjoys cooking, quilting, and watching television. Twenty-four hours after admission, the nurse notes that the client is withdrawn and isolated. It is best for the nurse to encourage this client to become involved in which activity?

• A. Clean the unit kitchen cabinets.
• B. Participate in a group quilting project.
• C. Watch television in the activity room.
• D. Bake a cake for a resident's birthday.

Correct answer: B

Rationale: Peer interaction in a group activity (B) such as participating in a group quilting project will help to prevent social isolation and withdrawal. This will provide the elderly client with an opportunity to engage with others, share experiences, and feel a sense of belonging. Choices (A, C, and D) are activities that can be accomplished alone, without peer interaction, which may not effectively address the client's feelings of withdrawal and isolation.

2. An emergency department nurse is caring for an adult client who is a victim of family violence. Which priority instruction would be included in the discharge instructions?

• A. Information regarding shelters
• B. Instructions regarding calling the police
• C. Instructions regarding self-defense classes
• D. Explaining the importance of leaving the violent situation

Correct answer: A

Rationale: The correct answer is A: Information regarding shelters. Providing information about shelters is crucial in cases of family violence as it ensures the client has a safe place to go after discharge, prioritizing their immediate safety. Option B, instructions regarding calling the police, may be necessary but ensuring a safe place to stay is more immediate. Option C, instructions regarding self-defense classes, may not be appropriate as the priority is to ensure the client's safety rather than teaching self-defense. Option D, explaining the importance of leaving the violent situation, is relevant but providing information on immediate shelter options is the priority.

3. A client with schizophrenia is being treated with haloperidol (Haldol). The LPN/LVN observes the client pacing in the hallway and appearing anxious. What should the nurse do first?

• A. Ask the client to sit down and relax.
• B. Administer a PRN dose of antipsychotic medication.
• C. Encourage the client to talk about what is making him anxious.
• D. Monitor the client for adverse reactions to the medication.

Correct answer: B

Rationale: Administering a PRN dose of antipsychotic medication is the first action the nurse should take to manage symptoms of anxiety in a client being treated with haloperidol. The priority is to address the client's escalating anxiety and pacing behavior, which can be managed effectively by providing additional antipsychotic medication. Asking the client to sit down and relax (Choice A) may not be effective if the anxiety is due to inadequate medication levels. Encouraging the client to talk about what is making him anxious (Choice C) may not be beneficial in this acute situation and can be considered after addressing the immediate need for symptom management. Monitoring for adverse reactions (Choice D) is important but is not the first action to take when the client is showing signs of increasing anxiety and agitation.

4. When a client with schizophrenia is being discharged on antipsychotic medication, what is the most important instruction the nurse should provide?

• A. Stop the medication if you start feeling better.
• B. Be aware of the potential for weight gain with this medication.
• C. Report any unusual muscle movements immediately.
• D. You can drive as soon as you feel ready.

Correct answer: C

Rationale: The correct answer is to instruct the client to report any unusual muscle movements immediately. These movements may indicate extrapyramidal symptoms (EPS) or tardive dyskinesia, which are serious side effects of antipsychotic medications that require immediate attention. Choice A is incorrect because stopping the medication without medical advice can lead to a relapse of symptoms. Choice B is important but not as critical as monitoring for EPS. Choice D is incorrect because driving readiness is not directly related to antipsychotic medication instructions.

5. The RN is providing care for a client diagnosed with borderline personality disorder who has self-inflicted lacerations on the abdomen. Which approach should the RN use when changing this client's dressing?

• A. Provide detailed explanations during wound cleansing.
• B. Perform the dressing change in a non-judgmental manner.
• C. Ask the client non-threateningly why they cut their abdomen.
• D. Request assistance from another staff member for the dressing change.

Correct answer: B

Rationale: Performing the dressing change in a non-judgmental manner is crucial when caring for a client with borderline personality disorder who has self-inflicted injuries. This approach helps build trust, reduces feelings of shame or guilt, and fosters a therapeutic relationship. Choice A is incorrect because while detailed explanations may be necessary, the focus should be on the non-judgmental approach. Choice C is inappropriate as it may come across as accusatory or threatening, potentially worsening the client's emotional state. Choice D is not the best option as the RN should strive to handle the situation themselves in a supportive and empathetic manner.

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