Nursing Elites

1. The community health nurse talks to a male client who has bipolar disorder. The client explains that he sleeps 4 to 5 hours a night and is working with his partner to start two new businesses and build an empire. The client stopped taking his medications several days ago. What nursing problem has the highest priority?

• A. Excessive work activity.
• B. Decreased need for sleep.
• C. Medication management.
• D. Inflated self-esteem.

Correct answer: D

Rationale: The priority is to manage the client's medication adherence to prevent escalation of manic behavior. Inflated self-esteem is the highest priority as it indicates the client's potential for harmful behaviors due to lack of medication compliance. While excessive work activity and decreased need for sleep are characteristics of mania, they are not as immediately concerning as the risk of harm related to inflated self-esteem.

2. A 22-year-old male client is admitted to the emergency center following a suicide attempt. His records reveal that this is his third suicide attempt in the past two years. He is conscious, but does not respond to verbal commands for treatment. Which assessment finding should prompt the nurse to prepare the client for gastric lavage?

• A. He ingested the drug 3 hours prior to admission to the emergency center.
• B. The family reports that he took an entire bottle of acetaminophen (Tylenol).
• C. He is unresponsive to instructions and is unable to cooperate with emetic therapy.
• D. Those with repeated suicide attempts desire punishment to relieve their guilt.

Correct answer: C

Rationale: The correct answer is C because the client's unresponsiveness to instructions and inability to cooperate with emetic therapy would make it challenging to implement such therapy effectively. In such cases, gastric lavage may be necessary to remove the ingested substance. Choices A and B are important considerations in treatment planning but do not directly indicate the need for gastric lavage. Choice D is incorrect as medical treatments should never be used as punitive measures but rather for therapeutic purposes.

3. A male client turns over a table in the dayroom of a psychiatric unit and threatens to throw a chair at another client. Which action is most important for the nurse to implement?

• A. Calmly approach the client and remove the chair from the client.
• B. Obtain staff assistance to help diffuse the escalating situation.
• C. Offer feedback about the client's behavior.
• D. Summon the hospital security guards as a 'show of force.'

Correct answer: B

Rationale: In a situation where a client is displaying aggressive behavior, the most important action for the nurse to implement is to obtain staff assistance to help diffuse the escalating situation. This approach ensures the safety of all individuals involved and prevents the situation from escalating further. Calmly approaching the client and removing the chair directly could agitate the client further and pose a risk to the nurse. Offering feedback about the client's behavior may not address the immediate safety concerns. Summoning hospital security guards as a 'show of force' should be a last resort after other de-escalation attempts have failed, as it may further provoke the client.

4. A young adult male client, diagnosed with paranoid schizophrenia, believes that the world is trying to poison him. What intervention should the nurse include in this client's plan of care?

• A. Remind the client that his suspicions are not true
• B. Ask one nurse to spend time with the client daily
• C. Encourage the client to participate in group activities
• D. Assign the client to a room closest to the activity room

Correct answer: B

Rationale: The correct intervention for a client diagnosed with paranoid schizophrenia who believes in paranoid delusions is to ask one nurse to spend time with the client daily. Establishing a trusting relationship with a consistent caregiver can help reduce anxiety and foster a sense of security. Choice A is incorrect because directly challenging the client's beliefs may increase distress. Choice C might overwhelm the client with paranoia in a group setting. Choice D does not address the need for a trusting relationship with a specific caregiver.

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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