Nursing Elites

1. A client with Alzheimer's disease is becoming increasingly agitated and combative in the late afternoon. What is the most appropriate intervention?

• A. Offer a sedative medication to calm the client.
• B. Encourage the client to rest in a quiet, low-stimulation environment.
• C. Use reality orientation to reduce confusion.
• D. Engage the client in physical activity to reduce agitation.

Correct answer: B

Rationale: Encouraging the client to rest in a quiet, low-stimulation environment is the most appropriate intervention for a client with Alzheimer's disease who is becoming agitated and combative in the late afternoon. This approach helps reduce agitation and prevent overstimulation, providing a calming and soothing environment for the client. Offering a sedative medication (Choice A) should be avoided as it may have side effects and should only be considered as a last resort. Reality orientation (Choice C) may increase confusion and distress in clients with advanced Alzheimer's disease. Engaging the client in physical activity (Choice D) could potentially escalate the agitation rather than reduce it in this scenario.

2. An adult male client who was admitted to the mental health unit yesterday tells the nurse that microchips were planted in his head for military surveillance of his every move. Which response is best for the nurse to provide?

• A. You are in the hospital, and I am the nurse caring for you
• B. It must be difficult for you to control your anxious feelings
• C. Go to occupational therapy and start a project
• D. You are not in a war area now; this is the United States

Correct answer: C

Rationale: Delusions often generate fear and isolation, so the nurse should help the client participate in activities that avoid focusing on the false belief and encourage interaction with others.

3. A male client is admitted to the mental health unit because he was feeling depressed about the loss of his wife and job. The client has a history of alcohol dependency and admits that he was drinking alcohol 12 hours ago. Vital signs are: temperature, 100 F, pulse 100, and BP 142/100. The nurse plans to give the client lorazepam (Ativan) based on which priority nursing diagnosis?

• A. Risk for injury related to suicidal ideation.
• B. Risk for injury related to alcohol detoxification.
• C. Knowledge deficit related to ineffective coping.
• D. Health-seeking behaviors related to personal crisis.

Correct answer: B

Rationale: The most important nursing diagnosis is related to alcohol detoxification (B) because the client has elevated vital signs, a sign of alcohol detoxification. Giving lorazepam (Ativan) to address the elevated vital signs due to alcohol withdrawal is a priority. Addressing the risk for injury related to suicidal ideation (A) should come after stabilizing the client's physiological state. Both (C) and (D) can be addressed once immediate safety needs are met, but the priority is managing the alcohol detoxification to prevent potential complications.

4. A woman brings her 48-year-old husband to the outpatient psychiatric unit and describes his behavior to the admitting nurse. She states that he has been sleepwalking, cannot remember who he is, and exhibits multiple personalities. The nurse knows that these behaviors are often associated with

• A. dissociative disorder.
• B. obsessive-compulsive disorder.
• C. panic disorder.
• D. post-traumatic stress disorder.

Correct answer: A

Rationale: The correct answer is A: dissociative disorder. Sleepwalking, amnesia, and multiple personalities are examples of detaching emotional conflict from one's consciousness, which is the definition of a dissociative disorder. Obsessive-compulsive disorder (B) is characterized by persistent, recurrent intrusive thoughts or urges (obsessions) and compulsions. Panic disorder (C) is characterized by acute attacks of anxiety. Post-traumatic stress disorder (D) involves re-experiencing psychologically distressing events.

5. A female client with anorexia nervosa is admitted to the hospital. What is the priority assessment for the nurse to perform?

• A. Assess the client's body image perception.
• B. Monitor the client's electrolyte levels.
• C. Evaluate the client's exercise habits.
• D. Assess the client's relationship with her family.

Correct answer: B

Rationale: The correct answer is to monitor the client's electrolyte levels. In clients with anorexia nervosa, electrolyte imbalances can lead to serious, potentially life-threatening complications such as cardiac arrhythmias. Assessing body image perception (choice A) is important but not the priority when compared to monitoring electrolyte levels. Evaluating exercise habits (choice C) and assessing the client's relationship with her family (choice D) are also important aspects of care but do not take precedence over monitoring electrolyte levels in a client with anorexia nervosa.

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