Nursing Elites

1. The nurse on the evening shift receives report that a client is scheduled for electroconvulsive treatment (ECT) in the morning. Which intervention should the nurse implement the evening before the scheduled ECT?

• A. Hold all bedtime medication.
• B. Keep the client NPO after midnight.
• C. Implement elopement precautions.
• D. Give the client an enema at bedtime.

Correct answer: B

Rationale: Keeping the client NPO after midnight is essential to prevent aspiration during the ECT procedure. Choice A, holding all bedtime medication, is not necessary unless specified by the healthcare provider. Choice C, implementing elopement precautions, is unrelated to preparing for ECT. Choice D, giving the client an enema at bedtime, is not a standard pre-ECT intervention.

2. A client with depression remains in bed most of the day and declines activities. Which nursing problem has the greatest priority for this client?

• A. Loss of interest in diversional activity.
• B. Social isolation.
• C. Refusal to address nutritional needs.
• D. Low self-esteem.

Correct answer: C

Rationale: The correct answer is C: 'Refusal to address nutritional needs.' When a client with depression remains in bed and declines activities, addressing their refusal to address nutritional needs is of utmost priority. Nutritional needs are essential for physical health and overall well-being. Inadequate nutrition can worsen the client's physical health, impact their mood, and hinder the effectiveness of treatment. Option A, 'Loss of interest in diversional activity,' while important, is not as critical as addressing nutritional needs for immediate physical well-being. Option B, 'Social isolation,' is a significant concern but addressing nutritional needs takes precedence due to its direct impact on physical health. Option D, 'Low self-esteem,' is a valid concern but does not take priority over addressing the client's refusal to meet their nutritional needs for immediate health benefits.

3. The RN is preparing medications for a client with bipolar disorder and notices that the client discontinued antipsychotic medication for several days. Which medication should also be discontinued?

• A. Lithium (Lithotabs).
• B. Benztropine (Cogentin).
• C. Alprazolam (Xanax).
• D. Magnesium (Milk of Magnesia).

Correct answer: B

Rationale: The correct answer is Benztropine (Cogentin). Benztropine is commonly prescribed to manage side effects of antipsychotic medications. Therefore, if the antipsychotic medication is discontinued, there would be no need for Benztropine. Lithium is a mood stabilizer used in bipolar disorder, not directly related to antipsychotic use. Alprazolam is an anxiolytic, and Magnesium (Milk of Magnesia) is a laxative, neither of which is typically associated with antipsychotic medication use.

4. A client with postpartum depression receives a prescription for sertraline (Zoloft). What information is most important to include in client teaching?

• A. Avoid foods high in tyramine, such as processed meats, red wine, and Swiss cheese.
• B. Contact the healthcare provider immediately if suicidal thoughts occur.
• C. Increase activity level to include regular exercise.
• D. Contact the healthcare provider immediately if muscle stiffness occurs.

Correct answer: B

Rationale: The most critical information to include in client teaching for a client with postpartum depression starting sertraline (Zoloft) is to contact the healthcare provider immediately if suicidal thoughts occur. This is vital for the client's safety as antidepressants, including sertraline, can sometimes increase the risk of suicidal thoughts, especially at the start of treatment. Choices A, C, and D are not the most crucial information in this scenario. Choice A about avoiding foods high in tyramine is not directly related to sertraline use. Choice C about increasing activity level is important but not as critical as addressing suicidal ideation. Choice D about muscle stiffness is a potential side effect of sertraline but is not as urgent as monitoring for suicidal thoughts.

5. A male client with schizophrenia is admitted to the mental health unit after abruptly stopping his prescription for ziprasidone (Geodon) one month ago. Which question is most important for the nurse to ask the client?

• A. Have you lost interest in activities you used to enjoy?
• B. Has your ability to think or concentrate decreased?
• C. How many consecutive hours do you sleep at night?
• D. Do you hear sounds or voices that others do not hear?

Correct answer: D

Rationale: Inquiring about hallucinations is crucial for assessing the return of psychotic symptoms due to discontinuation of antipsychotic medication. Hearing sounds or voices that others do not hear can indicate the presence of auditory hallucinations, a common symptom in schizophrenia. Choices A, B, and C are important aspects to assess in clients with schizophrenia, but in this scenario, the priority is to determine if the client is experiencing hallucinations, which can be a sign of worsening psychotic symptoms.

Similar Questions