Nursing Elites

1. When caring for a client who has overdosed on PCP, the nurse should be especially cautious about which of the following client behaviors?

• A. Visual hallucinations
• B. Violent behavior
• C. Bizarre behavior
• D. Loud screaming

Correct answer: B

Rationale: The correct answer is B: 'Violent behavior.' When a client has overdosed on PCP, the nurse should be particularly cautious about the manifestation of violent behavior. PCP overdose can lead to aggressive and unpredictable actions, posing a significant risk to both the client and healthcare providers. Visual hallucinations (choice A), bizarre behavior (choice C), and loud screaming (choice D) can also occur with PCP overdose, but the primary concern should be the potential for violent behavior, making it the most critical behavior to monitor and manage.

2. A client with schizophrenia is being treated with risperidone (Risperdal). The nurse notices that the client has a shuffling gait and tremors. What is the nurse's priority action?

• A. Administer a PRN dose of an anticholinergic medication.
• B. Document the findings and continue to monitor the client.
• C. Assess the client's blood glucose level.
• D. Notify the healthcare provider immediately.

Correct answer: A

Rationale: A shuffling gait and tremors may indicate extrapyramidal side effects (EPS) from risperidone. The nurse's priority action should be to administer an anticholinergic medication as it can help alleviate these symptoms associated with EPS. Documenting the findings and monitoring the client (Choice B) are important but addressing the immediate symptoms takes precedence. Assessing the client's blood glucose level (Choice C) is not directly related to the observed symptoms of shuffling gait and tremors. While notifying the healthcare provider (Choice D) is important, it is not the priority action when dealing with EPS symptoms.

3. A client with post-traumatic stress disorder (PTSD) reports having frequent nightmares. What is the nurse's best response?

• A. Nightmares are common with PTSD and should decrease over time.
• B. Try to avoid thinking about the trauma before going to bed.
• C. Let's discuss some relaxation techniques you can use before bedtime.
• D. I will ask the healthcare provider to prescribe a sleep aid.

Correct answer: C

Rationale: The best response for the nurse is to discuss relaxation techniques with the client that can help reduce anxiety and stress before bedtime. This approach may potentially decrease the frequency of nightmares by promoting a more calming and peaceful pre-sleep routine. Choice A is incorrect because while nightmares can be common with PTSD, it is not guaranteed that they will decrease over time. Choice B is incorrect as avoiding thinking about the trauma may not address the underlying issue causing the nightmares. Choice D is incorrect as prescribing a sleep aid should be considered as a last resort after trying non-pharmacological interventions.

4. How should the RN respond to the mother?

• A. Ask the mother if she has ever thought about harming herself or her child.
• B. Reassure the mother that her child will achieve some growth and development milestones.
• C. Determine if the mother has other children who do not have developmental disabilities.
• D. Encourage the mother to write her thoughts and feelings in a journal.

Correct answer: A

Rationale: The correct response is to ask the mother if she has ever thought about harming herself or her child. This is crucial to assess for suicidal or homicidal thoughts, ensuring the safety of both the mother and the child. Reassuring the mother about achieving some milestones may not address her immediate emotional distress. Inquiring about other children's developmental status is not the priority when safety concerns are present. While journaling can be therapeutic, in this situation, addressing safety takes precedence.

5. Which diet selection by a client who is depressed and taking the MAO inhibitor tranylcypromine sulfate (Parnate) indicates to the nurse that the client understands the dietary restrictions imposed by this medication regimen?

• A. Hamburger, French fries, and chocolate milkshake.
• B. Liver and onions, broccoli, and decaffeinated coffee.
• C. Pepperoni and cheese pizza, tossed salad, and a soft drink.
• D. Roast beef, baked potato with butter, and iced tea.

Correct answer: D

Rationale: The correct answer is (D) Roast beef, baked potato with butter, and iced tea. This diet selection indicates that the client understands the dietary restrictions imposed by taking tranylcypromine sulfate (Parnate) because it does not contain tyramine. Tyramine in foods can interact with MAO inhibitors like Parnate, leading to a hypertensive crisis, which is life-threatening. Choices (A, B, and C) contain foods high in tyramine like cheese, pepperoni, and chocolate, which are contraindicated for clients taking MAO inhibitors.

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