Nursing Elites

1. The LPN/LVN is assessing a client who is taking an antipsychotic medication. Which of the following symptoms is uniquely indicative of neuroleptic malignant syndrome (NMS) and requires immediate attention?

• A. Very high temperature
• B. Muscular rigidity
• C. Tremors
• D. Altered consciousness

Correct answer: A

Rationale: A very high temperature is a hallmark symptom of Neuroleptic Malignant Syndrome (NMS), which is a rare but potentially life-threatening side effect of antipsychotic medications. This symptom is uniquely indicative of NMS and requires immediate medical attention. Muscular rigidity, tremors, and altered consciousness can be seen in other conditions but are not as specifically linked to NMS as a very high temperature.

2. A 35-year-old male client on the psychiatric unit of a general hospital believes that someone is trying to poison him. The nurse understands that a client's delusions are most likely related to his

• A. early childhood experiences involving authority issues.
• B. anger about being hospitalized.
• C. low self-esteem.
• D. phobic fear of food.

Correct answer: C

Rationale: Psychotic clients often experience delusions due to difficulties with trust and low self-esteem (C). In this case, the client's belief that someone is trying to poison him is likely a manifestation of his underlying issues with trust and self-worth. Building trust and promoting positive self-esteem are essential in caring for such clients. Choices A, B, and D are incorrect because delusions are not primarily related to early childhood experiences involving authority issues, anger about hospitalization, or phobic fear of food. These factors do not directly contribute to the development of delusions in psychotic clients.

3. A 40-year-old male client diagnosed with schizophrenia and alcohol dependence has not had any visitors or phone calls since admission. He reports he has no family that cares about him and was living on the streets prior to this admission. According to Erikson's theory of psychosocial development, which stage is the client in at this time?

• A. Isolation.
• B. Stagnation.
• C. Despair.
• D. Role confusion.

Correct answer: B

Rationale: The client is in Erikson's 'Generativity vs. Stagnation' stage (age 24 to 45). This stage involves maintaining intimate relationships and moving toward developing a family, which the client seems to be struggling with due to lack of visitors and family support. Choices (A), (C), and (D) are incorrect. Isolation typically occurs in young adulthood (age 18 to 25), Despair in maturity (age 45 to death), and Role confusion in adolescence (age 12 to 20). These stages reflect challenges individuals face if they do not successfully navigate their psychosocial developmental tasks.

4. A teenaged client, a heroin addict, is admitted to the unit for detoxification. What intervention is most important for the nurse to initiate during the first 24 hours after admission?

• A. Assign the client to a teen support group.
• B. Assess intake and output.
• C. Monitor for wheezing and apnea.
• D. Limit visitors to family members only.

Correct answer: B

Rationale: Assessing intake and output is crucial during the first 24 hours after admission for detoxification. This helps the nurse monitor the client's hydration status and kidney function as the body goes through withdrawal from heroin. Option A is incorrect because joining a support group is beneficial but may not be the priority in the initial phase of detoxification. Option C, monitoring for wheezing and apnea, is important but not the most critical intervention during the first 24 hours. Option D, limiting visitors to family members only, is not directly related to the immediate needs of assessing intake and output.

5. The nurse is caring for a client who received the first-time electroconvulsive therapy (ECT) a half hour ago. Which action should the nurse implement first?

• A. Offer oral fluids.
• B. Monitor vital signs.
• C. Evaluate ECT effectiveness.
• D. Encourage group participation.

Correct answer: B

Rationale: After a client receives electroconvulsive therapy (ECT), the nurse's priority should be to monitor vital signs. This is important to ensure the client's physical stability and detect any immediate complications post-procedure. Offering oral fluids, evaluating ECT effectiveness, and encouraging group participation are all important aspects of care but monitoring vital signs takes precedence in the immediate post-ECT period.

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