Nursing Elites

1. In developing a plan of care for a client admitted to a mental health unit after attempting suicide by taking a handful of medications, which goal has the highest priority?

• A. Signs a no-self-harm contract
• B. Sleep for at least 6 hours nightly
• C. Attends group therapy every day
• D. Verbalizes a positive self-image

Correct answer: A

Rationale: The correct answer is A: Signs a no-self-harm contract. Ensuring the client’s immediate safety by having them commit to not engaging in self-harm is the highest priority after a suicide attempt. This measure aims to prevent further harm to the client. While sleep, group therapy, and self-image are important aspects of care, they are secondary to ensuring the client's safety in the immediate aftermath of a suicide attempt. Prioritizing the establishment of a no-self-harm contract creates a foundation for addressing other therapeutic goals in the client's care plan.

2. What information should the nurse include in the discharge teaching plan of a client with low back pain who is taking cyclobenzaprine to control muscle spasms?

• A. Take this medication with or without food
• B. Avoid using heat or ice on injured muscles while taking this medication
• C. Use cold and allergy medications only as directed by a healthcare provider
• D. Discontinue all nonsteroidal anti-inflammatory medications

Correct answer: C

Rationale: The correct answer is C: 'Use cold and allergy medications only as directed by a healthcare provider.' It is essential to inform the client not to self-medicate with cold and allergy medications or make changes without consulting a healthcare provider to prevent potential drug interactions or adverse effects. Choice A is incorrect because cyclobenzaprine can be taken with or without food, so there is no specific requirement to take it on an empty stomach. Choice B is incorrect because using heat or ice on injured muscles while taking cyclobenzaprine is generally safe and can help with symptom management. Choice D is also incorrect because discontinuing nonsteroidal anti-inflammatory medications should be done under the guidance of a healthcare provider, but it is not a direct concern related to taking cyclobenzaprine for muscle spasms.

3. A female client on the mental health unit frequently asks the nurse when she can be discharged. Then, becoming more anxious, she begins to pace the hallway. What intervention should the nurse implement first?

• A. Review the current treatment plan with the client
• B. Inform the healthcare provider about the client’s behaviors
• C. Determine if the client has PRN medication for anxiety
• D. Explore the client’s reasons for wanting to be discharged

Correct answer: D

Rationale: Exploring the client’s reasons for wanting to be discharged should be the first intervention as it helps to address underlying anxieties and concerns. By understanding the client's motivations, the nurse can provide appropriate support and interventions. It can also reduce distress and improve the therapeutic relationship. Reviewing the treatment plan (Choice A) may be important but addressing the immediate distress takes precedence. Informing the healthcare provider (Choice B) can be considered later if necessary. Determining if the client has PRN medication (Choice C) is relevant, but exploring the underlying reasons for the desire to be discharged is more beneficial in this situation.

4. A client with diabetic peripheral neuropathy has been taking pregabalin for 4 days. Which finding indicates to the nurse that the medication is effective?

• A. Granulating tissue in foot ulcer
• B. Full volume of pedal pulse
• C. Reduced level of pain
• D. Improved visual activity

Correct answer: C

Rationale: The correct answer is C: 'Reduced level of pain.' Pregabalin is used to manage neuropathic pain, so a reduction in pain indicates the medication's effectiveness in this case. Granulating tissue in a foot ulcer and the full volume of a pedal pulse are not direct indicators of pregabalin's effectiveness in managing neuropathic pain. Improved visual activity is not related to the effects of pregabalin in diabetic peripheral neuropathy.

5. A female client with borderline personality disorder is being discharged today. During morning rounds, the client complains about the aloofness of the night shift nurse and expresses joy to see the nurse on duty. Which response is best for the nurse to provide to this client’s dichotomous tendency?

• A. I am glad you like me. Which nurse was acting aloof to you?
• B. Tomorrow I will talk to that nurse about how you were treated last night.
• C. What did the night nurse do that makes you think she is aloof?
• D. I am happy that you are getting better and will be able to go home.

Correct answer: A

Rationale: Choice A is the best response as it acknowledges the client's feelings while exploring their concerns. By asking which nurse was acting aloof, the nurse shows understanding and allows the client to express their feelings further. This response validates the client's emotions and fosters a therapeutic relationship. Choice B focuses on a future action without addressing the immediate concern at hand. Choice C seeks clarification on the night nurse's behavior, which is a good approach but lacks the personal touch of Choice A. Choice D shifts the focus away from the client's current feelings and concerns, missing the opportunity to address the dichotomous thinking displayed by the client.

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