Nursing Elites

1. The nurse on the day shift receives report about a client with depression who was found on the floor in the morning. What intervention is best for the nurse to implement?

• A. Assist the client to get out of bed and involved in an activity.
• B. Monitor the client’s appetite and sleep patterns.
• C. Assess the client’s feelings regarding the hospital stay.
• D. Explain that staff will check on the client every 30 minutes.

Correct answer: A

Rationale: Assisting the client to engage in activities is the best intervention as it can help improve mood and prevent further decline in function. This intervention can also help the client regain a sense of control and purpose. Option B, monitoring appetite and sleep patterns, is important but not the most immediate intervention needed in this situation. Option C, assessing feelings about the hospital stay, is also important but addressing the client's physical safety and well-being should take precedence. Option D, explaining the frequency of staff checks, is not as effective in addressing the client's immediate needs for engagement and support.

2. Kyle, a patient with schizophrenia, began taking the first-generation antipsychotic haloperidol (Haldol) last week. One day you find him sitting very stiffly and not moving. He is diaphoretic, and when you ask if he is okay, he seems unable to respond verbally. His vital signs are: BP 170/100, P 110, T 104.2°F. What is the priority nursing intervention? Select all that apply.

• A. Hold his medication and contact his prescriber.
• B. Wipe him with a washcloth wet with cold water or alcohol.
• C. Administer a medication such as benztropine IM to correct this dystonic reaction.
• D. Reassure him that although there is no treatment for his tardive dyskinesia, it will pass.

Correct answer: C

Rationale: The correct intervention is to administer a medication such as benztropine IM to correct this dystonic reaction. The presentation of stiffness, diaphoresis, inability to respond verbally, and vital sign changes suggest an acute dystonic reaction, which is an extrapyramidal side effect of antipsychotic medications like haloperidol. Benztropine is an anticholinergic medication commonly used to manage these acute dystonic reactions. Option A is incorrect because holding the medication without addressing the acute symptoms may lead to worsening of the condition. Option B is incorrect as wiping with cold water or alcohol does not address the underlying cause of the symptoms. Option D is incorrect because it mentions tardive dyskinesia, which is a different condition characterized by involuntary movements that occur with long-term antipsychotic use, not the acute dystonic reaction seen here.

3. When preparing to administer a prescribed medication to a homeless male at a community psychiatric clinic, the client tells the nurse that he usually takes a different dosage. What action should the nurse take?

• A. Tell him to take the medication then verify the dosage at the next healthcare team meeting.
• B. Withhold the medication until the dosage can be confirmed.
• C. Inform him that he may refuse the medication and document whether or not he takes it.
• D. Explain to the client that the dosage has been changed.

Correct answer: B

Rationale: Withholding the medication until the dosage can be confirmed ensures patient safety and accuracy in treatment.

4. The client is being educated by the healthcare provider about starting a prescribed abstinence therapy with disulfiram (Antabuse). What information should the client understand?

• A. Maintain complete abstinence from alcohol consumption.
• B. Stay alcohol-free for at least 12 hours before the first dose.
• C. Participate in monthly therapy sessions.
• D. Disclose to others that he is receiving disulfiram therapy.

Correct answer: B

Rationale: The correct answer is B. Before starting disulfiram therapy (Antabuse), the client must comprehend the need to remain alcohol-free for a minimum of 12 hours. This is crucial to prevent the unpleasant and potentially dangerous reactions that can occur with concurrent alcohol consumption while on disulfiram. Choice A is incorrect because it mentions heroin or cocaine use, which is not the primary focus when initiating disulfiram therapy. Choice C is incorrect as it suggests therapy sessions, which are not specifically required before starting disulfiram. Choice D is incorrect as there is no need to disclose disulfiram therapy to others, but rather to adhere to the abstinence requirement.

5. A male client who recently lost a loved one arrives at the mental health center and tells the nurse he is no longer interested in his usual activities and has not slept for several days. Which priority nursing problem should the nurse include in this client’s plan of care?

• A. Risk for suicide
• B. Sleep deprivation
• C. Situational low self-esteem
• D. Social isolation

Correct answer: A

Rationale: The correct answer is A: Risk for suicide. Considering the client's recent loss, lack of interest in activities, and sleep disturbances, the nurse should prioritize assessing and addressing the risk for suicide. This client is displaying warning signs such as loss of interest in usual activities and sleep disturbances, which are commonly associated with suicidal ideation. B: Sleep deprivation is not the priority issue in this scenario, as the client's lack of sleep is likely a symptom of a deeper emotional struggle. C: Situational low self-esteem and D: Social isolation may be concerns for this client but do not take precedence over the immediate risk of suicide, given the presented symptoms.

Similar Questions