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 Twenty-four hours after admission, the nurse notes that the client is withdrawn and isolated.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. Which client outcome indicates improvement for a client who is admitted with auditory hallucinations?

• A. Argues with the voices.
• B. Tells when voices decrease.
• C. Follows what the voices say.
• D. Tells the nurse what the voices say.

Correct answer: B

Rationale: The correct answer is B: 'Tells when voices decrease.' This outcome indicates improvement because it shows that the client is experiencing a reduction in auditory hallucinations. By communicating that the voices are decreasing, it suggests that the client's symptoms are improving and the treatment is effective. Choices A, C, and D are incorrect. Arguing with the voices (A) indicates ongoing engagement with the hallucinations, which is not a positive outcome. Following what the voices say (C) suggests compliance with the hallucinations, which is not indicative of improvement. Lastly, telling the nurse what the voices say (D) does not necessarily demonstrate a reduction in hallucinations or improvement in the client's condition.

3. A client is scheduled to complete a positron emission tomography (PET) scan. The client asks the nurse to explain the reason the test was prescribed. How should the nurse respond?

• A. Images indicate the presence of tumors and scars.
• B. The scan clearly outlines structures of the brain.
• C. Results show activity in various portions of the brain.
• D. PET shows biochemical levels of neurotransmitters.

Correct answer: C

Rationale: The correct answer is C. PET scans are primarily used to detect and observe the metabolic activity in various parts of the brain. This helps in diagnosing conditions related to brain function, such as tumors, brain disorders, and overall brain activity. Choices A, B, and D are incorrect because PET scans focus on metabolic activity and functions in the brain rather than solely indicating the presence of tumors, outlining brain structures, or showing biochemical levels of neurotransmitters.

4. A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of risperidone (Risperdal). When the client walks to the nurse's station in a laterally contracted position, he states that something has made his body contort into a monster. What action should the nurse take?

• A. Medicate the client with the prescribed antipsychotic thioridazine (Mellaril).
• B. Offer the client a prescribed physical therapy hot pack for muscle spasms.
• C. Direct the client to occupational therapy to distract him from somatic complaints.
• D. Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia.

Correct answer: D

Rationale: The correct action for the nurse to take in this situation is to administer the prescribed anticholinergic benztropine (Cogentin) for dystonia. Dystonia can be a side effect of antipsychotic medications like risperidone, leading to involuntary muscle contractions and abnormal postures. Benztropine is an anticholinergic medication commonly used to treat dystonia. Choices A, B, and C are incorrect because thioridazine is not the appropriate medication in this case, a hot pack would not address the underlying issue of dystonia, and occupational therapy is not the primary intervention for addressing acute dystonic reactions.

5. An LPN/LVN is caring for a suicidal client. The appropriate nursing intervention in dealing with this client is to:

• A. Demonstrate confidence in the client's ability to deal with stressors
• B. Provide hope and reassurance that the problems will resolve themselves
• C. Display an attitude of detachment, confrontation, and efficiency
• D. Provide authority, action, and participation

Correct answer: D

Rationale: When caring for a suicidal client, providing authority, taking action, and encouraging the client's participation in their care are essential. Choice A is incorrect as it may not be sufficient for the critical situation of a suicidal client. Choice B, while offering hope, may not address the immediate risk of harm. Choice C's attitude of detachment and confrontation can be counterproductive in establishing trust and rapport with the client. Therefore, the most appropriate intervention is to provide authority, take action to ensure safety, and involve the client in the care process.

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