Nursing Elites

1. A client diagnosed with paranoid schizophrenia states, 'The FBI is watching me. I see their agents everywhere.' Which is the nurse's most appropriate response?

• A. You shouldn't worry about that. It's not real.
• B. I don't see any FBI agents, but it sounds like you're feeling frightened.
• C. Let's talk about something else to take your mind off of it.
• D. Why do you think the FBI is watching you?

Correct answer: B

Rationale: Validating the client's feelings without reinforcing the delusion is important. This response acknowledges the client's fear without agreeing with the delusion. It shows empathy and understanding towards the client's emotions while not validating the delusional belief.

2. A client is prescribed diazepam (Valium) for anxiety. Which statement by the client indicates a need for further teaching?

• A. I can drink alcohol while taking this medication.
• B. I should avoid drinking alcohol while taking this medication.
• C. I should take this medication only when I feel anxious.
• D. I can stop taking this medication when I feel better.

Correct answer: A

Rationale: The correct answer is A because clients should avoid alcohol while taking diazepam (Valium) due to potential interactions. Alcohol can increase the sedative effects of diazepam, leading to excessive drowsiness or respiratory depression. Choice B is correct as it reflects the need to avoid alcohol. Choice C is incorrect because diazepam is usually taken regularly, not just when feeling anxious. Choice D is incorrect as abruptly stopping diazepam can lead to withdrawal symptoms and should be done gradually under medical supervision.

3. Maggie, a child in protective custody, is found to have an imaginary friend, Holly. Her foster family shares this information with the nurse. The nurse teaches the family members about children who have suffered trauma and knows her teaching was effective when the foster mother states:

• A. I understand that imaginary friends are abnormal.
• B. I understand that imaginary friends are a maladaptive behavior.
• C. I understand that imaginary friends are a coping mechanism.
• D. I understand that we should tell the child that imaginary friends are unacceptable.

Correct answer: C

Rationale: Imaginary friends can serve as a coping mechanism for children, especially those who have experienced trauma. They can provide comfort and a sense of control in challenging situations. Acknowledging and supporting the child's imaginary friend can be beneficial in their emotional healing and development.

4. A client with bipolar disorder is experiencing a depressive episode. Which intervention should the nurse implement to support the client's recovery?

• A. Encourage the client to engage in physical activity.
• B. Encourage the client to maintain a regular sleep schedule.
• C. Encourage the client to set realistic goals for daily activities.
• D. Encourage the client to express feelings of sadness.

Correct answer: C

Rationale: During a depressive episode in bipolar disorder, encouraging the client to set realistic goals for daily activities can be beneficial. Setting achievable goals can provide structure, a sense of accomplishment, and help in breaking tasks into manageable steps, which can support the client's recovery process. Options A and B, while important in managing bipolar disorder, may not directly address the client's depressive symptoms during this episode. Option D, encouraging the client to express feelings of sadness, is not as effective as setting achievable goals in providing structure and a sense of accomplishment during a depressive episode.

5. When caring for a client with anorexia nervosa in a psychiatric unit, which intervention should the nurse implement to address the client's nutritional needs?

• A. Provide small, frequent meals throughout the day.
• B. Monitor the client's weight daily.
• C. Offer a liquid supplement if the client refuses solid food.
• D. Encourage the client to choose from a variety of food options.

Correct answer: A

Rationale: Providing small, frequent meals throughout the day is a crucial intervention when caring for a client with anorexia nervosa. This approach helps in gradually increasing caloric intake and meeting the client's nutritional needs. Offering large meals can be overwhelming and may contribute to anxiety in these clients. By providing small, frequent meals, the nurse supports the client in establishing a healthier eating pattern and aids in the restoration of adequate nutrition levels. Monitoring the client's weight daily (Choice B) may exacerbate anxiety related to body image and weight, which are common concerns in anorexia nervosa. Offering a liquid supplement if the client refuses solid food (Choice C) may not address the underlying issues related to food aversion and may not provide the necessary nutrients in a balanced way. Encouraging the client to choose from a variety of food options (Choice D) may be overwhelming for someone with anorexia nervosa and could lead to increased anxiety around food choices.

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