Nursing Elites

1. A client who recently experienced the death of a significant other arrives at the mental health center. The client reports loss of interest in usual activities, expresses a wish to be with the deceased significant other, has been eating very little, and has not slept in several days. Which client statement is most important for the RN to explore at this time?

• A. Not sleeping for several days.
• B. Wishing to be with the deceased significant other.
• C. Lack of interest in usual activities.
• D. Eating very little.

Correct answer: A

Rationale: The most important client statement for the RN to explore in this scenario is the client not sleeping for several days. The lack of sleep is a critical indicator of possible severe depression or suicidal ideation that requires immediate attention. While expressing a wish to be with the deceased significant other, having a lack of interest in usual activities, and eating very little are concerning, the immediate focus should be on the client's severe sleep disturbance as it can pose an immediate risk to their well-being and safety.

2. A client with depression remains in bed most of the day, declines activities, and refuses meals. Which nursing problem has the greatest priority for this client?

• A. Loss of interest in diversional activities.
• B. Social isolation.
• C. Refusal to address nutritional needs.
• D. Low self-esteem.

Correct answer: C

Rationale: The correct answer is C: 'Refusal to address nutritional needs.' In this scenario, the client's refusal to eat and address their nutritional needs poses an immediate threat to their physical health. Without proper nutrition, the client is at risk of malnutrition and its associated complications. While addressing social isolation, low self-esteem, and loss of interest in diversional activities are important aspects of holistic care for a client with depression, ensuring proper nutrition takes precedence due to the critical impact it has on the client's physical well-being. Therefore, the priority is to address the client's refusal to eat and address their nutritional needs to prevent further deterioration of their health.

3. When preparing to administer a prescribed medication to a homeless male at a community psychiatric clinic, the client tells the nurse that he usually takes a different dosage. What action should the nurse take?

• A. Tell him to take the medication then verify the dosage at the next healthcare team meeting.
• B. Withhold the medication until the dosage can be confirmed.
• C. Inform him that he may refuse the medication and document whether or not he takes it.
• D. Explain to the client that the dosage has been changed.

Correct answer: B

Rationale: Withholding the medication until the dosage can be confirmed ensures patient safety and accuracy in treatment.

4. A client with obsessive-compulsive disorder (OCD) is receiving a new prescription for fluoxetine (Prozac). Which statement by the client indicates an understanding of this medication?

• A. “I should begin feeling less anxious within a few weeks.”
• B. “The drug will help me control my compulsive behaviors.”
• C. “I will need to have a weekly blood test to check my liver function.”
• D. “I should avoid foods that contain tyramine while taking this medication.”

Correct answer: B

Rationale: The correct answer is B. Fluoxetine, an SSRI, can help manage symptoms of OCD by assisting in controlling compulsive behaviors rather than directly reducing anxiety. The improvement in symptoms usually occurs over a few weeks. Choice A is incorrect as it provides a timeframe for anxiety improvement, which is not the primary goal of fluoxetine in OCD treatment. Choice C is incorrect as routine blood tests are not typically required with fluoxetine. Choice D is incorrect as avoiding tyramine-containing foods is more relevant for MAOIs, not SSRIs like fluoxetine.

5. The RN documents the mental status of a female client who has been hospitalized for several days by court order. The client states, “I don’t need to be here,” and tells the RN that she believes that the TV talks to her. The RN should document these assessment statements in which section of the mental status exam?

• A. Insight and judgment.
• B. Mood and affect.
• C. Remote memory.
• D. Level of concentration.

Correct answer: A

Rationale: The client's statement of not needing to be hospitalized and her belief that the TV talks to her indicate impaired insight and judgment. Insight and judgment evaluate the client's awareness of their condition and ability to make sound decisions. Mood and affect assess emotional state, remote memory evaluates recall of past events, and level of concentration assesses attention and focus. In this scenario, the client's lack of awareness of her need for hospitalization and presence of delusions about the TV speaking to her directly relate to insight and judgment, making choice A the correct option.

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