Nursing Elites

1. To provide effective care for a patient diagnosed with schizophrenia, what associated condition should the nurse frequently assess for? Select all that apply.

• A. Alcohol use disorder
• B. Major depressive disorder
• C. Stomach cancer
• D. Polydipsia

Correct answer: A

Rationale: Alcohol use disorder is commonly associated with schizophrenia, leading to a dual diagnosis. Assessing for alcohol use disorder is crucial in managing the patient's overall well-being and treatment plan. Major depressive disorder can co-occur with schizophrenia but is not the most commonly associated condition. Stomach cancer is not typically associated with schizophrenia. Polydipsia, excessive thirst, can be a symptom in some individuals with schizophrenia due to medication side effects, but it is not an associated condition that requires frequent assessment compared to alcohol use disorder.

2. A male client with bipolar disorder tells the nurse that he needs to 'make some deals so that he can improve his retirement savings.' Based on this information, which client outcome should the nurse include in the plan of care?

• A. Delay business decisions until his mania subsides.
• B. Identify the feelings associated with his behaviors.
• C. Seek legal counsel when making business decisions.
• D. Describe why he is feeling fearful about his finances.

Correct answer: A

Rationale: In individuals with bipolar disorder experiencing mania, impulsivity and poor judgment are common. Delaying business decisions until the mania subsides is crucial to prevent impulsive and potentially harmful financial choices. Choice B, identifying feelings associated with behaviors, may be important but does not directly address the immediate need to prevent risky financial decisions. Seeking legal counsel (Choice C) may be appropriate in some situations but is not the priority in managing acute mania. Describing why he feels fearful about finances (Choice D) is relevant for understanding emotions but does not address the immediate risk of impulsive financial actions during mania.

3. The RN is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. Which strategies should be included in the safety plan? (SOA)

• A. Purchase a gun for protection.
• B. Establish a code with family and friends to signal violence.
• C. Take a self-defense course focused on protection.
• D. Prepare a bag with extra clothes for self and children.

Correct answer: B

Rationale: Establishing a code with family and friends is crucial in situations of intimate partner violence as it allows discreet communication for help without alerting the abuser. Having a pre-prepared bag with essentials like extra clothes is important to facilitate a quick exit if necessary. Purchasing a gun is not a recommended safety strategy as it can escalate violence and pose more danger. While taking a self-defense course focused on protection is beneficial, it is essential to avoid courses that emphasize retaliation, as they can increase the risk and escalate violence.

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

• A. Hold all bedtime medications.
• 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 the appropriate intervention before ECT to prevent complications during the procedure. Withholding food and fluids reduces the risk of aspiration and helps ensure the safety of the client. Option A (Hold all bedtime medications) is incorrect because medications may need to be given as prescribed unless specified otherwise by the healthcare provider. Option C (Implement elopement precautions) is unrelated to preparing a client for ECT and focuses on preventing a client from leaving the treatment area. Option D (Give the client an enema at bedtime) is unnecessary and not a standard pre-ECT preparation, making it an incorrect choice.

5. The RN documents the mental status of a female client who has been hospitalized for several days by court order. The client states, “I don’t need to be here,” and tells the RN that she believes that the TV talks to her. The RN should document these assessment statements in which section of the mental status exam?

• A. Insight and judgment.
• B. Mood and affect.
• C. Remote memory.
• D. Level of concentration.

Correct answer: A

Rationale: The client's statement of not needing to be hospitalized and her belief that the TV talks to her indicate impaired insight and judgment. Insight and judgment evaluate the client's awareness of their condition and ability to make sound decisions. Mood and affect assess emotional state, remote memory evaluates recall of past events, and level of concentration assesses attention and focus. In this scenario, the client's lack of awareness of her need for hospitalization and presence of delusions about the TV speaking to her directly relate to insight and judgment, making choice A the correct option.

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