Nursing Elites

1. 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.

2. A male client with schizophrenia tells the nurse that the FBI is monitoring his phone calls. What is the nurse's best response?

• A. Let's talk about your feelings of being monitored.
• B. There is no evidence that the FBI is monitoring your calls.
• C. Why do you think the FBI is interested in your phone calls?
• D. I can assure you that your phone calls are not being monitored.

Correct answer: A

Rationale: The correct response is to choose A: 'Let's talk about your feelings of being monitored.' This response shows empathy and encourages the client to express his feelings. Engaging the client in a discussion about his feelings can help address underlying fears without directly challenging the delusion. Choice B is incorrect because directly denying the delusion may lead to increased distrust or agitation in the client. Choice C may come across as confrontational, which can exacerbate the client's paranoia. Choice D offers a false sense of assurance and does not address the client's concerns effectively.

3. Within several days of hospitalization, a client is repeatedly washing the top of the same table. Which initial intervention is best for the nurse to implement to help the client cope with anxiety related to this behavior?

• A. Administer a prescribed PRN antianxiety medication.
• B. Assist the client in identifying stimuli that precipitate the ritualistic activity.
• C. Allow time for the ritualistic behavior, then redirect the client to other activities.
• D. Teach the client relaxation and thought-stopping techniques.

Correct answer: C

Rationale: Initially, the nurse should allow time for the ritualistic behavior (C) to prevent anxiety. Administering an antianxiety medication (A) may help reduce the client's anxiety temporarily but will not address the underlying issue of ineffective coping mechanisms leading to the behavior. While assisting the client in identifying triggers (B) is important for long-term therapy, the immediate focus should be on managing the behavior. Teaching relaxation and thought-stopping techniques (D) is beneficial but might be more effective once the client is more stable and receptive to learning new coping strategies.

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 diagnosed with bipolar disorder tells the nurse that she wants to stop taking her lithium. She states, 'I feel fine, and I don't think I need it anymore.' What should the nurse do first?

• A. Agree with the client that she seems fine now.
• B. Remind the client of the importance of lithium.
• C. Ask the healthcare provider to discontinue the lithium prescription.
• D. Arrange for a psychiatric evaluation for the client.

Correct answer: B

Rationale: When a client with bipolar disorder expresses a desire to stop taking lithium because they feel fine, the nurse's initial action should be to remind the client of the importance of lithium. This approach helps educate the client about the necessity of medication adherence in managing bipolar disorder. Agreeing with the client or immediately arranging a psychiatric evaluation may not address the root issue of medication non-adherence. Asking the healthcare provider to discontinue the prescription without further assessment and intervention could potentially jeopardize the client's stability and treatment plan.

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