Nursing Elites

1. The nurse is preparing to administer phenelzine sulfate (Nardil) to a client on the psychiatric unit. Which complaint related to administration of this drug should the nurse expect this client to make?

• A. My mouth feels like cotton.
• B. That medication gives me indigestion.
• C. This pill gives me diarrhea.
• D. My urine looks pink.

Correct answer: A

Rationale: Dry mouth is a common side effect of MAO inhibitors like phenelzine due to their anticholinergic effects. Choices B, C, and D are incorrect as indigestion, diarrhea, and pink urine are not commonly associated side effects of phenelzine.

2. A client in a long-term care facility who has multiple sclerosis is embarrassed about the need to use a wheelchair and the muscle spasms that are readily visible in her legs. Which approach is therapeutic in assisting the client to cope?

• A. Keep the client in her room as much as possible
• B. Assist the client with all activities of daily living
• C. Tell the client that many of the people in the facility have these same sorts of problems
• D. Encourage and praise perseverance in performing ADLs, and assist the client to dress and groom daily

Correct answer: D

Rationale: Encouraging and praising the client's perseverance in performing activities of daily living (ADLs) is therapeutic as it helps the client maintain a sense of normalcy and dignity, thus supporting their psychosocial well-being. This approach acknowledges the client's struggles while empowering them to maintain their independence and self-care. Choices A and C are incorrect as they do not address the client's emotional needs and may contribute to further isolation and distress. Choice B, while important, does not specifically address the client's feelings of embarrassment and the need for emotional support.

3. A homeless person who is in the manic phase of bipolar disorder is admitted to the mental health unit. Which laboratory finding obtained on admission is most important for the nurse to report to the healthcare provider?

• A. Decreased thyroid stimulating hormone level
• B. Elevated liver function profile
• C. Increased white blood cell count
• D. Decreased hematocrit and hemoglobin levels

Correct answer: A

Rationale: The correct answer is A: Decreased thyroid stimulating hormone level. Hyperthyroidism causes an increased level of serum thyroid hormones (T3 and T4), which inhibit the release of TSH. In this case, a decreased TSH level can indicate hyperthyroidism, which can present with manic behavior. Elevated liver function profile (B) is not directly related to the manic phase of bipolar disorder. Increased white blood cell count (C) typically indicates an infection or inflammation, not directly related to the manic phase. Decreased hematocrit and hemoglobin levels (D) may suggest anemia but are not as crucial in the context of a manic phase of bipolar disorder.

4. A 46-year-old female client has been on antipsychotic neuroleptic medication for the past three days. She has had a decrease in psychotic behavior and appears to be responding well to the medication. On the fourth day, the client's blood pressure increases, she becomes pale and febrile, and demonstrates muscular rigidity. Which action will the nurse initiate?

• A. Place the client on seizure precautions and monitor closely.
• B. Immediately transfer the client to the ICU.
• C. Report the symptoms to the charge nurse and document in the client's chart.
• D. No action is required at this time as these are known side effects of such medications.

Correct answer: B

Rationale: These symptoms are indicative of neuroleptic malignant syndrome (NMS), which is a severe and life-threatening reaction to neuroleptic drugs. The major symptoms include fever, rigidity, autonomic instability, and encephalopathy. Respiratory failure, cardiovascular collapse, arrhythmias, and/or renal failure can lead to death. This is an emergency situation requiring immediate critical care, thus the correct action is to transfer the client to the ICU (B). Seizure precautions (A) are not relevant in this scenario. Merely describing the symptoms to the charge nurse and documenting them (C) or taking no action assuming these are common side effects (D) fail to address the critical nature of the situation and the urgency of immediate intervention.

5. A client who has been diagnosed with borderline personality disorder is exhibiting manipulative behavior. What is the most important intervention for the LPN/LVN to implement?

• A. Set clear, consistent limits on manipulative behavior.
• B. Ignore the manipulative behavior to avoid reinforcing it.
• C. Remind the client that manipulative behavior is unacceptable.
• D. Explain the consequences of manipulative behavior to the client.

Correct answer: A

Rationale: Setting clear, consistent limits on manipulative behavior is the most important intervention for a client diagnosed with borderline personality disorder. This approach helps establish boundaries, maintain a therapeutic environment, and provide structure for the client. Choice B is incorrect because ignoring manipulative behavior can lead to its reinforcement. Choice C, while important, may not be as effective as directly setting limits. Choice D focuses on consequences rather than immediate intervention, making it less effective than setting clear limits.

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