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. A client on the psychiatric unit appears to imitate a certain nurse on the unit. The client seeks out this particular nurse and imitates her mannerisms. Which defense mechanism does the nurse recognize in this client?

• A. Sublimation.
• B. Identification.
• C. Introjection.
• D. Repression.

Correct answer: B

Rationale: Identification is the correct answer. It is a defense mechanism where an individual unconsciously models themselves after someone they admire or feel close to. In this scenario, the client is imitating the nurse's mannerisms, indicating identification. Sublimation involves channeling unacceptable impulses into socially acceptable activities. Introjection is the internalization of external attitudes or voices, while repression involves suppressing unwanted thoughts or desires.

3. A client with schizophrenia is being treated with haloperidol (Haldol) and begins to exhibit symptoms of tardive dyskinesia. What is the nurse's priority action?

• A. Continue the medication and monitor for worsening symptoms.
• B. Administer the next dose of haloperidol with food.
• C. Report the symptoms to the healthcare provider immediately.
• D. Educate the client about the side effects of haloperidol.

Correct answer: C

Rationale: The correct answer is to report the symptoms to the healthcare provider immediately. Tardive dyskinesia is a serious side effect of antipsychotic medications, including haloperidol. Prompt reporting is crucial to evaluate the need for medication adjustment or change in treatment. Continuing the medication without intervention (choice A) can worsen the symptoms. Administering the next dose (choice B) is not appropriate when tardive dyskinesia is suspected. Educating the client (choice D) is important but not the priority when dealing with acute symptoms of tardive dyskinesia.

4. The nurse is planning the care for a 32-year-old male client with acute depression. Which nursing intervention would be best in helping this client deal with his depression?

• A. Ensure that the client's day is filled with group activities.
• B. Assist the client in exploring feelings of shame, anger, and guilt.
• C. Allow the client to initiate and determine activities of daily living.
• D. Encourage the client to explore the rationale for his depression.

Correct answer: B

Rationale: Assisting the client in exploring feelings of shame, anger, and guilt (B) is the most appropriate intervention for acute depression as it helps address core emotions that may be contributing to the condition. Focusing on these emotions can aid the client in processing and coping with their feelings. Ensuring that the client's day is filled with group activities (A) might overwhelm the client, as they may not be ready for social interactions during this sensitive time. Allowing the client to initiate and determine activities of daily living (C) is more suitable for chronic cases where the client needs to regain autonomy. Encouraging the client to explore the rationale for his depression (D) is less effective in acute cases, as the focus should be on immediate emotional support and understanding rather than cognitive analysis.

5. At the first meeting of a group of older adults at a daycare center for the elderly, the nurse asks one of the members what kinds of things she would like to do with the group. The older woman shrugs her shoulders and says, 'You tell me, you're the leader.' What is the best response for the nurse to make?

• A. 'Yes, I am the leader today. Would you like to be the leader tomorrow?'
• B. 'Yes, I will be leading this group. What would you like to accomplish during this time?'
• C. 'Yes, I have been assigned to be the leader of this group. I will be here for the next six weeks.'
• D. 'Yes, I am the leader. You seem angry about not being the leader yourself.'

Correct answer: B

Rationale: (B) provides information and focuses the group back to defining its function. (A) is manipulative bargaining. (C) does not focus on the group’s purpose. (D) challenges the client’s feelings.

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