Nursing Elites

1. The nurse is admitting a male client who takes lithium carbonate (Eskalith) twice a day. Which information should the nurse report to the healthcare provider immediately?

• A. Short-term memory loss.
• B. Depressed affect.
• C. Five-pound weight gain.
• D. Nausea and vomiting.

Correct answer: D

Rationale: Nausea and vomiting should be reported immediately because they could indicate lithium toxicity, which requires urgent medical attention to prevent more severe effects. Short-term memory loss, depressed affect, and weight gain are common side effects of lithium but do not require immediate medical attention compared to symptoms of toxicity like nausea and vomiting.

2. A client with a history of bipolar disorder presents to the emergency department with symptoms of mania. What is the priority nursing intervention?

• A. Administer prescribed medication to manage symptoms.
• B. Provide a calm environment with minimal stimulation.
• C. Encourage the client to express feelings and emotions.
• D. Reinforce the need for consistent medication adherence.

Correct answer: A

Rationale: Administering prescribed medication to manage symptoms is the priority intervention for a client with symptoms of mania. During a manic episode, the client may be at risk of harm to self or others due to impulsivity and poor judgment. Medication helps stabilize the client, reduce manic symptoms, and prevent further escalation. Providing a calm environment (choice B) is important but not the priority when the client's safety is at risk. Encouraging expression of feelings (choice C) and reinforcing medication adherence (choice D) are valuable aspects of care but addressing the acute symptoms of mania takes precedence to ensure the client's immediate safety and well-being.

3. A 35-year-old male client on the psychiatric ward 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: The correct answer is C: low self-esteem. Delusions of persecution, like being poisoned, are often rooted in underlying issues of low self-esteem and trust. Option A is incorrect because the delusion is not necessarily related to early childhood experiences involving authority issues. Option B is incorrect as there is no information provided that suggests the client's delusion is driven by anger about being hospitalized. Option D is incorrect as the delusion is about being poisoned, not a phobic fear of food.

4. An elderly female client with advanced dementia is admitted to the hospital with a fractured hip. The client repeatedly tells the staff, 'Take me home. I want my Mommy.' Which response is best for the nurse to provide?

• A. Orient the client to the time, place, and person.
• B. Tell the client that the nurse is there and will help her.
• C. Remind the client that her mother is no longer living.
• D. Explain the seriousness of her injury and need for hospitalization.

Correct answer: B

Rationale: Those with dementia often refer to home or parents when seeking security and comfort. The nurse should use the techniques of 'offering self' and 'talking to the feelings' to provide reassurance (B). Clients with advanced dementia have permanent physiological changes in the brain (plaques and tangles) that prevent them from comprehending and retaining new information, so choices A, C, and D are likely to be of little use to this client and do not address the emotional needs expressed by the client. Option B acknowledges the client's feelings, offers support, and provides reassurance, which can help comfort the client during this distressing time.

5. A client with schizophrenia is being treated with haloperidol (Haldol) and begins to exhibit symptoms of tardive dyskinesia. What is the nurse's priority action?

• A. Continue the medication and monitor for worsening symptoms.
• B. Administer the next dose of haloperidol with food.
• C. Report the symptoms to the healthcare provider immediately.
• D. Educate the client about the side effects of haloperidol.

Correct answer: C

Rationale: The correct answer is to report the symptoms to the healthcare provider immediately. Tardive dyskinesia is a serious side effect of antipsychotic medications, including haloperidol. Prompt reporting is crucial to evaluate the need for medication adjustment or change in treatment. Continuing the medication without intervention (choice A) can worsen the symptoms. Administering the next dose (choice B) is not appropriate when tardive dyskinesia is suspected. Educating the client (choice D) is important but not the priority when dealing with acute symptoms of tardive dyskinesia.

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