Nursing Elites

1. The client is planning discharge for a male client with schizophrenia. The client insists that he is returning to his apartment, although the healthcare provider informed him that he will be moving to a boarding home. What is the most important nursing diagnosis for discharge planning?

• A. Ineffective denial related to situational anxiety.
• B. Ineffective coping related to inadequate support.
• C. Social isolation related to difficult interactions.
• D. Self-care deficit related to cognitive impairment.

Correct answer: A

Rationale: The best nursing diagnosis is (A) because the client is unable to acknowledge the move to a boarding home. While (B, C, and D) are potential nursing diagnoses, denial is the most critical as it is a defense mechanism preventing the client from addressing his feelings regarding the change in living arrangements.

2. A client with generalized anxiety disorder is being taught about buspirone (BuSpar) by a nurse. Which statement by the client indicates a need for further teaching?

• A. I should take this medication on an empty stomach.
• B. It may take several weeks before I feel better.
• C. This medication does not cause dependence.
• D. I can drink alcohol while taking this medication.

Correct answer: D

Rationale: The statement 'I can drink alcohol while taking this medication' (D) indicates a need for further teaching. Clients should avoid alcohol while taking buspirone because it can increase the risk of side effects such as dizziness and drowsiness. Choices A, B, and C are correct statements regarding buspirone and do not require further teaching.

3. The nurse observes a female client with schizophrenia watching the news on TV. She begins to laugh softly and says, 'Yes, my love, I'll do it.' When the nurse questions the client about her comment, she states, 'The news commentator is my lover, and he speaks to me each evening. Only I can understand what he says.' What is the best response for the nurse to make?

• A. What do you believe the news commentator said to you?
• B. Let's watch the news on a different television channel.
• C. Does the news commentator have plans to harm you or others?
• D. The news commentator is not talking to you.

Correct answer: A

Rationale: The correct response for the nurse is to ask the client, 'What do you believe the news commentator said to you?' This is important to determine the content of the auditory hallucination and understand the client's perception. Choice B is incorrect as changing the TV channel does not address the underlying issue. Choice C is incorrect as it introduces a paranoid idea that the news commentator may have harmful intentions, which is not supported by the scenario. Choice D is incorrect as it dismisses the client's belief without exploring or validating her experience.

4. What is the most important nursing intervention during the first 48 hours for a client with anorexia nervosa admitted to the hospital?

• A. Providing high-calorie, high-protein meals.
• B. Monitoring vital signs and electrolytes.
• C. Encouraging the client to talk about feelings.
• D. Observing for signs of purging.

Correct answer: B

Rationale: The most important nursing intervention during the first 48 hours for a client with anorexia nervosa is monitoring vital signs and electrolytes (B) to assess for life-threatening complications. This helps in early detection of any physiological imbalances that could lead to serious consequences. Providing high-calorie, high-protein meals (A) is important for nutritional rehabilitation but comes after ensuring the client's physical stability. Encouraging the client to talk about feelings (C) and observing for signs of purging (D) are relevant aspects of care but are not as critical as monitoring vital signs and electrolytes in the initial phase of treatment.

5. An older homeless client visits the psychiatric clinic to obtain a prescription renewal for alprazolam (Xanax). During the health assessment, the client complains of chest pain. Which action should the RN take first?

• A. Refer the client to the cardiology unit.
• B. Obtain the client's blood pressure.
• C. Assess the client for substance abuse.
• D. Determine if Xanax was taken recently.

Correct answer: D

Rationale: Determining if Xanax was taken recently is crucial as it helps assess whether the chest pain is related to medication use or another issue, guiding appropriate immediate care. This action can provide essential information to address the client's current complaint effectively. Referring the client to the cardiology unit (Choice A) may be premature without assessing the Xanax use first. While obtaining the client's blood pressure (Choice B) is important, it is not the priority when the client presents with chest pain and a history of taking Xanax. Assessing the client for substance abuse (Choice C) is also important but is secondary to first determining the potential link between Xanax and the chest pain.

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