Nursing Elites

1. The nurse is planning client teaching for a 35-year-old client with early alcoholic cirrhosis. Which self-care measure should the nurse emphasize for the client’s recovery?

• A. Support group meetings.
• B. Vitamin B and multivitamin supplements.
• C. Diet with adequate calories and protein.
• D. Alcohol abstinence.

Correct answer: D

Rationale: Alcohol abstinence is the most critical self-care measure for a client with early alcoholic cirrhosis. Continued alcohol consumption can lead to further liver damage and worsen the condition. Support group meetings may offer emotional support but do not address the root cause of the issue. While vitamin supplements and a nutritious diet are important for overall health, alcohol abstinence takes precedence in managing cirrhosis caused by alcohol consumption.

2. An RN is providing education to the family of a client diagnosed with schizophrenia who is being treated with clozapine (Clozaril). The RN should instruct the family to report which symptom immediately?

• A. Sore throat
• B. Weight loss
• C. Constipation
• D. Lightheadedness

Correct answer: A

Rationale: The correct answer is A: Sore throat. Clozapine can lead to agranulocytosis, a condition characterized by a significant decrease in white blood cells. A sore throat can be an early sign of agranulocytosis, a potentially life-threatening adverse effect of clozapine. The family should report this symptom immediately to the healthcare provider for further evaluation and management. Choices B, C, and D are incorrect because weight loss, constipation, and lightheadedness are not typically associated with the serious adverse effect of agranulocytosis related to clozapine therapy.

3. During a group session on anger management, a male adolescent client is fidgety, interrupts peers, and talks about his pets at home. What action should the nurse take?

• A. Allow the client to leave and return in 10 minutes.
• B. Explore the client’s feelings about his pets and home life.
• C. Encourage his peers to help involve him in the activity.
• D. Redirect him by encouraging him to read from the handout.

Correct answer: D

Rationale: The best nursing action in this scenario is to redirect the client by encouraging him to read from the handout. This approach helps refocus the client's attention on the topic being discussed, which is anger management. Choice A is not appropriate as it may disrupt the group session and does not address the client's behavior. Choice B, while important in understanding the client's background, does not address the immediate disruptive behavior. Choice C involves others to manage the client's behavior instead of direct intervention by the nurse, which may not be effective in this situation.

4. During admission to the psychiatric unit, a female client is extremely anxious and states that she is worried about the sun coming up the next day. What intervention is most important for the RN to implement during the admission process?

• A. Assist the client in developing alternative coping skills.
• B. Remain calm and use a matter-of-fact approach.
• C. Ask the client why she is so anxious.
• D. Administer a PRN sedative to help relieve her anxiety.

Correct answer: B

Rationale: During admission to a psychiatric unit, it is crucial for the registered nurse to remain calm and use a matter-of-fact approach when addressing a client who is extremely anxious. By staying composed and adopting a matter-of-fact demeanor, the nurse can help establish trust and promote a sense of calm in the client. This approach can also convey a sense of reassurance and stability, which can be beneficial in managing the client's anxiety. Assisting the client in developing alternative coping skills (Choice A) may be important in the long term but is not the most immediate priority during the admission process. Asking the client why she is anxious (Choice C) may not be helpful at this moment as the client may not be able to articulate the specific reasons due to her heightened anxiety. Administering a PRN sedative (Choice D) should not be the initial intervention as it does not address the underlying cause of the anxiety and should be considered only if other non-pharmacological interventions are ineffective.

5. A client who is admitted to the mental health unit reports shortness of breath and dizziness. The client tells the nurse, “I feel like I’m going to die.” Which nursing problem should the nurse include in this client’s plan of care?

• A. Mood disturbance
• B. Moderate anxiety
• C. Altered thoughts
• D. Social isolation

Correct answer: B

Rationale: The correct answer is B: Moderate anxiety. When a client presents with symptoms such as shortness of breath, dizziness, and a fear of dying, it indicates moderate anxiety. Anxiety can manifest physically with symptoms like these. Mood disturbance (choice A) refers to a change in mood, while altered thoughts (choice C) relate to cognitive changes. Social isolation (choice D) involves a lack of social interaction, which is not the primary concern in this scenario where the client is experiencing acute anxiety symptoms.

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