Nursing Elites

1. When preparing to administer a domestic violence screening tool to a female client, which statement should the RN provide?

• A. If you are experiencing abuse from your partner, I am required to ask you these questions.
• B. It is a requirement by law for me to inquire if you are a victim of domestic violence.
• C. Your healthcare provider must be informed if you are facing any domestic abuse.
• D. All clients undergo screening for domestic abuse due to its prevalence in our society.

Correct answer: D

Rationale: The correct answer is D because screening all clients for domestic abuse as a routine part of care helps in early identification and support. Choice A is incorrect as it may imply that the questions are only asked if abuse is already suspected. Choice B is incorrect because it emphasizes the legal obligation rather than the importance of routine screening. Choice C is incorrect as it focuses on the healthcare provider's need rather than the benefit to the client of routine screening.

2. An RN is providing education to the family of a client diagnosed with schizophrenia who is being treated with clozapine (Clozaril). The RN should instruct the family to report which symptom immediately?

• A. Sore throat
• B. Weight loss
• C. Constipation
• D. Lightheadedness

Correct answer: A

Rationale: The correct answer is A: Sore throat. Clozapine can lead to agranulocytosis, a condition characterized by a significant decrease in white blood cells. A sore throat can be an early sign of agranulocytosis, a potentially life-threatening adverse effect of clozapine. The family should report this symptom immediately to the healthcare provider for further evaluation and management. Choices B, C, and D are incorrect because weight loss, constipation, and lightheadedness are not typically associated with the serious adverse effect of agranulocytosis related to clozapine therapy.

3. A healthcare professional is preparing to provide medication education to a client who has just been prescribed an antipsychotic medication. What should the healthcare professional include in the teaching plan?

• A. “You should have regular eye exams.”
• B. “It is important to avoid caffeine while on this medication.”
• C. “You may experience dry mouth and blurred vision.”
• D. “You should increase your intake of vitamin C to prevent side effects.”

Correct answer: C

Rationale: The correct answer is C. Antipsychotic medications often have anticholinergic side effects like dry mouth and blurred vision. Teaching the client about these potential side effects is essential for their understanding and management. Regular eye exams (Choice A) are not specifically related to antipsychotic medications. While avoiding caffeine (Choice B) might be a general good practice, it is not a specific side effect of antipsychotic medications. Increasing vitamin C intake (Choice D) is not a standard recommendation for preventing antipsychotic medication side effects.

4. Kyle, a patient with schizophrenia, began taking the first-generation antipsychotic haloperidol (Haldol) last week. One day you find him sitting very stiffly and not moving. He is diaphoretic, and when you ask if he is okay, he seems unable to respond verbally. His vital signs are: BP 170/100, P 110, T 104.2°F. What is the priority nursing intervention? Select all that apply.

• A. Hold his medication and contact his prescriber.
• B. Wipe him with a washcloth wet with cold water or alcohol.
• C. Administer a medication such as benztropine IM to correct this dystonic reaction.
• D. Reassure him that although there is no treatment for his tardive dyskinesia, it will pass.

Correct answer: C

Rationale: The correct intervention is to administer a medication such as benztropine IM to correct this dystonic reaction. The presentation of stiffness, diaphoresis, inability to respond verbally, and vital sign changes suggest an acute dystonic reaction, which is an extrapyramidal side effect of antipsychotic medications like haloperidol. Benztropine is an anticholinergic medication commonly used to manage these acute dystonic reactions. Option A is incorrect because holding the medication without addressing the acute symptoms may lead to worsening of the condition. Option B is incorrect as wiping with cold water or alcohol does not address the underlying cause of the symptoms. Option D is incorrect because it mentions tardive dyskinesia, which is a different condition characterized by involuntary movements that occur with long-term antipsychotic use, not the acute dystonic reaction seen here.

5. Which client statement suggests to the nurse that the client is using the defense mechanism of projection to deal with anxiety related to admission to a psychiatric unit?

• A. I am here because the police thought I was doing something wrong
• B. At least I hit the wall instead of hitting the psychiatric aide
• C. I want to be here because I know it is the best psychiatric facility
• D. Don’t believe everything my family tells you, I am not crazy

Correct answer: B

Rationale: The correct answer is B because the client is projecting their aggressive impulses onto an inanimate object, the wall, instead of accepting their own feelings. This statement reflects the defense mechanism of projection. Choice A is not projection; it is an explanation of why the client is there. Choice C indicates acceptance of the facility and does not involve projection. Choice D is a denial statement rather than projection.

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