Nursing Elites

1. A client who is admitted to the mental health unit reports shortness of breath and dizziness. The client tells the nurse, “I feel like I’m going to die.” Which nursing problem should the nurse include in this client’s plan of care?

• A. Mood disturbance
• B. Moderate anxiety
• C. Altered thoughts
• D. Social isolation

Correct answer: B

Rationale: The correct answer is B: Moderate anxiety. When a client presents with symptoms such as shortness of breath, dizziness, and a fear of dying, it indicates moderate anxiety. Anxiety can manifest physically with symptoms like these. Mood disturbance (choice A) refers to a change in mood, while altered thoughts (choice C) relate to cognitive changes. Social isolation (choice D) involves a lack of social interaction, which is not the primary concern in this scenario where the client is experiencing acute anxiety symptoms.

2. A client is receiving substitution therapy during withdrawal from benzodiazepines. Which expected outcome statement has the highest priority when planning nursing care?

• A. Excessive CNS stimulation will be reduced.
• B. Co-dependent behaviors will be decreased.
• C. Client’s level of consciousness will increase.
• D. Client will not demonstrate cross-addiction.

Correct answer: A

Rationale: The correct answer is A: 'Excessive CNS stimulation will be reduced.' During benzodiazepine withdrawal, the priority is to manage symptoms such as CNS hyperactivity, which can include agitation, anxiety, and seizures. Substitution therapy aims to minimize these withdrawal symptoms by providing a safer alternative to the benzodiazepine. Options B, C, and D are not the highest priority during benzodiazepine withdrawal. Decreasing co-dependent behaviors, increasing the client's level of consciousness, and preventing cross-addiction are important aspects of care but are not as critical as managing the potentially severe CNS stimulation.

3. The RN is preparing medications for a client with bipolar disorder and notices that the client discontinued antipsychotic medication for several days. Which medication should also be discontinued?

• A. Lithium (Lithotabs).
• B. Benztropine (Cogentin).
• C. Alprazolam (Xanax).
• D. Magnesium (Milk of Magnesia).

Correct answer: B

Rationale: The correct answer is Benztropine (Cogentin). Benztropine is commonly prescribed to manage side effects of antipsychotic medications. Therefore, if the antipsychotic medication is discontinued, there would be no need for Benztropine. Lithium is a mood stabilizer used in bipolar disorder, not directly related to antipsychotic use. Alprazolam is an anxiolytic, and Magnesium (Milk of Magnesia) is a laxative, neither of which is typically associated with antipsychotic medication use.

4. A client with an eating disorder tells the RN, 'I’ve been eating only 400 calories per day and have been taking diuretics to lose weight.' What is the RN’s best response?

• A. “Your diet is very harmful and needs to be changed immediately.”
• B. “It’s important to monitor your calorie intake carefully.”
• C. “Have you noticed any physical effects from this low-calorie diet?”
• D. “The diuretics could be causing your body to lose essential nutrients.”

Correct answer: D

Rationale: The correct response is D. By addressing the potential harm of diuretics and the low-calorie diet, the nurse effectively addresses both aspects of the client's disordered eating behavior. Choice A is too direct and does not provide information on the specific issue of diuretics. Choice B focuses solely on monitoring calorie intake without addressing the use of diuretics. Choice C inquires about physical effects but does not address the overall risks associated with diuretics and low-calorie intake.

5. A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The nurse also determines that the client is homeless and slightly suspicious. This client’s treatment plan should include what priority problem?

• A. Self-care deficit.
• B. Disturbed sensory perception.
• C. Ineffective community coping.
• D. Acute confusion.

Correct answer: D

Rationale: The correct answer is 'D: Acute confusion.' In the given scenario, the client is disoriented, disorganized, and confused, indicating acute confusion. This is a priority issue to address for immediate safety and appropriate care. Option A, self-care deficit, is not the priority as the client's safety and mental status take precedence over self-care. Option B, disturbed sensory perception, is not applicable as the client's symptoms focus more on cognitive rather than sensory issues. Option C, ineffective community coping, is not the immediate concern as the client's cognitive state needs urgent attention to ensure her safety and well-being.

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