Nursing Elites

1. A 22-year-old male client is admitted to the emergency center following a suicide attempt. His records reveal that this is his third suicide attempt in the past two years. He is conscious, but does not respond to verbal commands for treatment. Which assessment finding should prompt the nurse to prepare the client for gastric lavage?

• A. He ingested the drug 3 hours prior to admission to the emergency center.
• B. The family reports that he took an entire bottle of acetaminophen (Tylenol).
• C. He is unresponsive to instructions and is unable to cooperate with emetic therapy.
• D. Those with repeated suicide attempts desire punishment to relieve their guilt.

Correct answer: C

Rationale: The correct answer is C because the client's unresponsiveness and inability to cooperate with emetic therapy indicate the need for gastric lavage. Gastric lavage is a procedure used to remove toxic substances from the stomach in cases where the patient is unresponsive or unable to cooperate. Choice A is incorrect as the time of ingestion alone does not indicate the need for gastric lavage. Choice B, although indicating a significant overdose, does not directly necessitate gastric lavage. Choice D is incorrect as it provides information about the possible psychological motivation for repeated suicide attempts, but it is not directly related to the immediate need for gastric lavage in this scenario.

2. A young adult female client is admitted to a psychiatric facility with a medical diagnosis of bulimia nervosa. Which nursing intervention has the highest priority?

• A. Schedule the client for group therapy with other clients with bulimia nervosa.
• B. Assign the client's care to a nurse with relevant experience in eating disorders.
• C. Monitor the client carefully for binging and purging activities.
• D. Assess and report the client's electrolyte status to the healthcare provider.

Correct answer: D

Rationale: The correct answer is D. Assessing and reporting the client's electrolyte status to the healthcare provider is the highest priority in a client with bulimia nervosa. Electrolyte imbalances, such as hypokalemia and metabolic alkalosis, are common due to purging behaviors associated with bulimia. Monitoring electrolyte levels is crucial to prevent life-threatening complications. Choices A, B, and C are incorrect because while therapy and monitoring for binging activities are important, addressing the electrolyte imbalances caused by purging behaviors takes precedence in the immediate care of a client with bulimia nervosa.

3. A client with Alzheimer's disease is becoming increasingly agitated and combative in the late afternoon. What is the most appropriate intervention?

• A. Offer a sedative medication to calm the client.
• B. Encourage the client to rest in a quiet, low-stimulation environment.
• C. Use reality orientation to reduce confusion.
• D. Engage the client in physical activity to reduce agitation.

Correct answer: B

Rationale: Encouraging the client to rest in a quiet, low-stimulation environment is the most appropriate intervention for a client with Alzheimer's disease who is becoming agitated and combative in the late afternoon. This approach helps reduce agitation and prevent overstimulation, providing a calming and soothing environment for the client. Offering a sedative medication (Choice A) should be avoided as it may have side effects and should only be considered as a last resort. Reality orientation (Choice C) may increase confusion and distress in clients with advanced Alzheimer's disease. Engaging the client in physical activity (Choice D) could potentially escalate the agitation rather than reduce it in this scenario.

4. A 45-year-old female client is admitted to the psychiatric unit for evaluation. Her husband states that she has been reluctant to leave home for the last six months. The client has not gone to work for a month and has been terminated from her job. She has not left the house since that time. This client is displaying symptoms of what condition?

• A. Claustrophobia
• B. Acrophobia
• C. Agoraphobia
• D. Post-traumatic stress disorder

Correct answer: C

Rationale: The correct answer is C: Agoraphobia. Agoraphobia is the fear of crowds or being in open places, often leading individuals to avoid situations where they feel trapped, insecure, or out of control. In the case described, the client's reluctance to leave home, avoidance of work, and isolation within the house are indicative of agoraphobia. Claustrophobia (A) is the fear of closed places, while acrophobia (B) is the fear of high places. Post-traumatic stress disorder (D) involves the development of anxiety symptoms following a traumatic event, characterized by terror, fear, and helplessness, and is different from a phobia.

5. A 52-year-old male client in the intensive care unit who has been oriented suddenly becomes disoriented and fearful. Assessment of vital signs and other physical parameters reveal no significant change, and the nurse formulates the diagnosis, 'Confusion related to ICU psychosis.' Which intervention would be best to implement?

• A. Move all machines away from the client's immediate area.
• B. Attempt to allay the client's fears by explaining the etiology of his condition.
• C. Cluster care so that brief periods of rest can be scheduled during the day.
• D. Extend visitation times for family and friends.

Correct answer: C

Rationale: In critical care environments, stressors can lead to isolation and confusion. Providing the client with scheduled rest periods (C) can help alleviate these symptoms. Moving all machines away (A) is impractical as they are often essential. Explaining the condition (B) may not be effective during acute confusion. Extending visitation times (D) can be overwhelming for the client in the ICU.

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