Nursing Elites

1. The nurse should hold the next scheduled dose of a client's haloperidol (Haldol) based on which assessment finding(s)?

• A. Dizziness when standing.
• B. Shuffling gait and hand tremors.
• C. Urinary retention.
• D. Fever of 102°F.

Correct answer: D

Rationale: A fever (D) may indicate neuroleptic malignant syndrome (NMS), a potentially fatal complication of antipsychotics. The healthcare provider should be contacted before administering the next dose of Haldol. Dizziness when standing (A), shuffling gait and hand tremors (B), and urinary retention (C) are all adverse effects of Haldol that, while concerning, do not pose immediate life-threatening risks compared to the potential severity of NMS indicated by a fever.

2. The nurse is caring for a client who received the first-time electroconvulsive therapy (ECT) a half hour ago. Which action should the nurse implement first?

• A. Offer oral fluids.
• B. Monitor vital signs.
• C. Evaluate ECT effectiveness.
• D. Encourage group participation.

Correct answer: B

Rationale: After a client receives electroconvulsive therapy (ECT), the nurse's priority should be to monitor vital signs. This is important to ensure the client's physical stability and detect any immediate complications post-procedure. Offering oral fluids, evaluating ECT effectiveness, and encouraging group participation are all important aspects of care but monitoring vital signs takes precedence in the immediate post-ECT period.

3. A client with major depressive disorder is prescribed an SSRI. After one week, the client reports feeling no improvement in mood. What is the best response by the RN?

• A. It is common for antidepressants to take several weeks to have an effect.
• B. We may need to switch to a different medication.
• C. You should feel better by now, let's discuss this with your doctor.
• D. Maybe you are not taking the medication as prescribed.

Correct answer: A

Rationale: The correct response is A: 'It is common for antidepressants to take several weeks to have an effect.' This response is appropriate because SSRI and other antidepressants often require several weeks to exhibit improvement in mood. It is crucial to educate the client about this delay to manage expectations and promote adherence to the medication regimen. Choice B is incorrect as switching medications prematurely is not typically recommended after just one week. Choice C is incorrect because it sets unrealistic expectations for immediate improvement. Choice D is incorrect as it may come across as accusatory and should not be the initial response.

4. A female client with depression attends group and states that she sometimes misses her medication appointments because she feels very anxious about riding the bus. Which statement is the nurse's best response?

• A. Can your case manager take you to your appointments?
• B. Take your medication for anxiety before you ride the bus.
• C. Let's talk about what happens when you feel very anxious.
• D. What are some ways that you can cope with your anxiety?

Correct answer: D

Rationale: The best response is to explore ways for the client to cope with anxiety (D). The nurse should encourage problem-solving rather than dependence on the case manager (A) for transportation. While taking medication for anxiety before riding the bus may be helpful, addressing coping strategies should come first (B). Although discussing the feelings of anxiety can be therapeutic (C), the most appropriate approach is to engage the client in finding ways to manage her anxiety effectively.

5. A 65-year-old female client complains to the nurse that recently she has been hearing voices. What question should the nurse ask this client first?

• A. Do you have problems with hallucinations?
• B. Are you ever alone when you hear the voices?
• C. Has anyone in your family had hearing problems?
• D. Do you see things that others cannot see?

Correct answer: B

Rationale: The nurse should first ask if the client is ever alone when she hears the voices. This question helps differentiate between potential auditory hallucinations and other causes like hearing loss. Choice A is not the best first question as it assumes the client is experiencing hallucinations without exploring other possibilities. Choice C is irrelevant to the immediate concern of hearing voices. Choice D pertains to visual hallucinations which are not described in the client's complaint of hearing voices.

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