Nursing Elites

1. A 30-year-old sales manager tells the nurse, 'I am thinking about a job change. I don't feel like I am living up to my potential.' Which of Maslow's developmental stages is the sales manager attempting to achieve?

• A. Self-Actualization
• B. Loving and Belonging
• C. Basic Needs
• D. Safety and Security

Correct answer: A

Rationale: The correct answer is 'Self-Actualization.' Self-actualization is the highest level of Maslow's hierarchy of needs, focusing on fulfilling one's full potential and achieving personal growth. In this scenario, the sales manager expressing a desire for a job change because they don't feel they are living up to their potential aligns with the characteristics of self-actualization. Choices B, C, and D represent lower levels of Maslow's hierarchy: 'Loving and Belonging' pertains to social needs, 'Basic Needs' encompass physiological and safety needs, and 'Safety and Security' are fundamental needs related to protection and stability.

2. A client with schizophrenia is being treated with haloperidol (Haldol). The LPN/LVN observes the client pacing in the hallway and appearing anxious. What should the nurse do first?

• A. Ask the client to sit down and relax.
• B. Administer a PRN dose of antipsychotic medication.
• C. Encourage the client to talk about what is making him anxious.
• D. Monitor the client for adverse reactions to the medication.

Correct answer: B

Rationale: Administering a PRN dose of antipsychotic medication is the first action the nurse should take to manage symptoms of anxiety in a client being treated with haloperidol. The priority is to address the client's escalating anxiety and pacing behavior, which can be managed effectively by providing additional antipsychotic medication. Asking the client to sit down and relax (Choice A) may not be effective if the anxiety is due to inadequate medication levels. Encouraging the client to talk about what is making him anxious (Choice C) may not be beneficial in this acute situation and can be considered after addressing the immediate need for symptom management. Monitoring for adverse reactions (Choice D) is important but is not the first action to take when the client is showing signs of increasing anxiety and agitation.

3. A client in the mental health unit believes that the food is being poisoned. What intervention(s) would be helpful when attempting to encourage the client to eat? Select one that does not apply.

• A. Use open-ended questions to encourage client dialogue
• B. Offer opinions about the necessity for adequate nutrition
• C. Focus on the client's self-disclosure about food preferences
• D. Identify the reasons the client has for not wanting to eat

Correct answer: B

Rationale: Using open-ended questions and focusing on the client's self-disclosure about food preferences can help build rapport and trust with the client, encouraging them to eat. Identifying the reasons the client has for not wanting to eat can provide insights into their concerns. However, offering opinions about the necessity for adequate nutrition may come across as imposing views on the client, potentially leading to resistance. This approach may not be as effective in encouraging the client to eat as it could create a power dynamic that hinders the therapeutic relationship.

4. A client with schizophrenia is being treated with haloperidol (Haldol). The client reports feeling restless and unable to sit still. What should the nurse do first?

• A. Instruct the client to take deep breaths and relax.
• B. Assess the client for signs of akathisia.
• C. Encourage the client to engage in physical activity.
• D. Administer a PRN dose of lorazepam (Ativan).

Correct answer: B

Rationale: Restlessness and inability to sit still are signs of akathisia, an extrapyramidal side effect of antipsychotic medications. The nurse should first assess the client for signs of akathisia by observing their movements and behavior. Assessing for akathisia is crucial to differentiate it from other conditions and to intervene appropriately. Instructing the client to relax or engage in physical activity may not address the underlying issue of akathisia. Administering lorazepam should not be the first action as it may mask the symptoms of akathisia temporarily without addressing the root cause.

5. A client, who is on a 30-day commitment to a drug rehabilitation unit, asks the nurse if he can go for a walk on the grounds of the treatment center. When he is told that his privileges do not include walking on the grounds, the client becomes verbally abusive. Which approach will the nurse take?

• A. Call a staff member to escort the client to his room.
• B. Tell the client to talk to his healthcare provider about his privileges.
• C. Remind the client of the unit rules.
• D. Ignore the client's inappropriate behavior.

Correct answer: C

Rationale: (C) is the correct approach in this situation as it reinforces unit rules, setting clear boundaries and expectations. By reminding the client of the unit rules, the nurse is helping to maintain a safe and structured environment within the drug rehabilitation unit. (A) is unnecessary since the client's behavior does not warrant immediate physical intervention. (B) is not ideal because the client's privileges have already been explained, and suggesting he speak to his healthcare provider may not address the immediate issue. (D) is not appropriate as addressing inappropriate behavior is essential in a therapeutic setting.

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