Nursing Elites

1. A client is admitted to the mental health unit and reports taking extra anti-anxiety medication because, 'I'm so stressed out. I just wanted to go to sleep.' The nurse should plan one-on-one observation of the client based on which statement?

• A. What should I do? Nothing seems to help.
• B. I have been so tired lately and needed to sleep.
• C. I really think that I don't need to be here.
• D. I don't want to talk. Nothing matters anymore.

Correct answer: D

Rationale: The correct answer is D because expressing feelings of hopelessness or nihilism can be indicators of a deeper, possibly dangerous level of depression. Choice A is incorrect as it indicates seeking help, Choice B suggests fatigue, and Choice C implies denial of needing help, none of which directly signify severe depression warranting one-on-one observation.

2. A LVN/LPN is caring for a client with anorexia nervosa. The nurse is monitoring the behavior of the client and understands that a client with anorexia nervosa manages anxiety by:

• A. Engaging in immoral acts
• B. Always reinforcing self-approval
• C. Observing rigid rules and regulations
• D. Having the need always to make the right decision

Correct answer: C

Rationale: Clients with anorexia nervosa often manage anxiety by adhering strictly to rules and regulations as a way to maintain control. Choice A is incorrect because engaging in immoral acts is not a common coping mechanism for clients with anorexia nervosa. Choice B is incorrect as self-approval is not typically the primary way clients with anorexia nervosa manage anxiety. Choice D is incorrect because while clients with anorexia nervosa may have a need to make the right decision, it is not the primary way they manage their anxiety.

3. A client with schizophrenia is being discharged with a prescription for risperidone (Risperdal). What is the most important information for the nurse to provide?

• A. You need to have regular blood tests while taking this medication.
• B. Report any muscle stiffness or unusual movements immediately.
• C. Avoid foods high in tyramine while taking this medication.
• D. This medication may cause weight loss.

Correct answer: B

Rationale: The correct answer is B: "Report any muscle stiffness or unusual movements immediately." This information is crucial because muscle stiffness or unusual movements may indicate extrapyramidal symptoms (EPS), a potential side effect of risperidone that requires immediate attention. Choice A is less critical as regular blood tests are important but not as urgent as identifying EPS. Choice C is irrelevant as tyramine interactions are not associated with risperidone. Choice D is incorrect as weight gain is more common than weight loss with risperidone.

4. A 35-year-old male client on the psychiatric unit of a general hospital believes that someone is trying to poison him. The nurse understands that a client's delusions are most likely related to his

• A. early childhood experiences involving authority issues.
• B. anger about being hospitalized.
• C. low self-esteem.
• D. phobic fear of food.

Correct answer: C

Rationale: Psychotic clients often experience delusions due to difficulties with trust and low self-esteem (C). In this case, the client's belief that someone is trying to poison him is likely a manifestation of his underlying issues with trust and self-worth. Building trust and promoting positive self-esteem are essential in caring for such clients. Choices A, B, and D are incorrect because delusions are not primarily related to early childhood experiences involving authority issues, anger about hospitalization, or phobic fear of food. These factors do not directly contribute to the development of delusions in psychotic clients.

5. A male employee who is assessed weekly in the employee clinic for blood pressure because of a history of hypertension tells the nurse that he is so upset with one of his co-workers that he would like to shoot him. What action should the nurse take first?

• A. Determine if the client has a weapon available for use.
• B. Inform the health care provider of the threat to harm a co-worker.
• C. Notify security of the client's intention to harm a co-worker.
• D. Have the employee escorted to a mental health facility.

Correct answer: A

Rationale: Determining if the client has access to a weapon is critical for immediate safety and to prevent potential harm.

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