Nursing Elites

1. A client with bipolar disorder is experiencing a manic episode. Which intervention should the nurse implement to ensure the client's safety?

• A. Provide a structured environment with minimal stimuli.
• B. Monitor the client closely for signs of exhaustion.
• C. Encourage the client to rest and sleep as needed.
• D. Encourage the client to engage in regular physical activity.

Correct answer: A

Rationale: During a manic episode in bipolar disorder, individuals may exhibit increased energy levels, impulsivity, and reduced need for sleep, which can lead to risky behaviors and accidents. Providing a structured environment with minimal stimuli helps to reduce the risk of overstimulation and impulsive actions, thereby promoting the client's safety. This intervention aims to create a calm and controlled setting that can prevent potential harm to the client during this phase of the disorder.

2. A client is diagnosed with obsessive-compulsive disorder (OCD). Which of the following interventions should the nurse include in the care plan? Select one that does not apply.

• A. Allow the client to perform rituals initially
• B. Set limits on the time allowed for rituals
• C. Encourage the client to verbalize feelings
• D. Provide a structured schedule of activities

Correct answer: A

Rationale: Interventions for a client with OCD should include allowing the client to perform rituals initially, setting limits on the time allowed for rituals, encouraging the client to verbalize feelings, and providing a structured schedule of activities. Allowing the client to perform rituals is an essential part of managing OCD and should not be restricted in the initial stages of care. Setting limits on the time for rituals helps prevent excessive engagement in them. Encouraging the client to verbalize feelings promotes emotional expression and processing. Providing a structured schedule of activities helps establish routine and predictability, which can be beneficial for individuals with OCD.

3. When assessing a patient with schizophrenia who exhibits flat affect and social withdrawal, these symptoms are classified as:

• A. Positive symptoms
• B. Negative symptoms
• C. Cognitive symptoms
• D. Mood symptoms

Correct answer: B

Rationale: Flat affect and social withdrawal are characteristic of negative symptoms in schizophrenia. Negative symptoms involve disruptions to normal emotions and behaviors, such as reduced emotional expression (flat affect) and social withdrawal. These symptoms reflect a decrease or absence of normal functions. Positive symptoms, on the other hand, involve the presence of abnormal behaviors or experiences, such as hallucinations and delusions, which are added to a person’s experiences. Cognitive symptoms relate to difficulties with thinking, memory, and processing information, impacting cognition. Mood symptoms involve disturbances in mood regulation, which is distinct from the flat affect seen in negative symptoms.

4. A client with generalized anxiety disorder is prescribed buspirone. Which statement by the client indicates a need for further teaching?

• A. I can stop taking this medication once I feel less anxious.
• B. I should avoid drinking alcohol while taking this medication.
• C. It may take several weeks for this medication to take full effect.
• D. This medication can cause dependency.

Correct answer: A

Rationale: The correct answer is A because it indicates a misunderstanding about buspirone. Buspirone should not be abruptly stopped, and patients should follow the prescribed regimen consistently. Stopping the medication without proper guidance can lead to adverse effects or a return of anxiety symptoms. Choices B, C, and D demonstrate an understanding of important aspects of buspirone therapy: avoiding alcohol due to interactions, being patient for the medication to reach full effectiveness, and being aware of the potential for dependency with this medication.

5. When caring for a client experiencing alcohol withdrawal, which intervention should the nurse implement to prevent complications?

• A. Provide a well-lit environment.
• B. Administer antipsychotic medication as prescribed.
• C. Monitor the client's vital signs closely.
• D. Encourage the client to express their feelings.

Correct answer: C

Rationale: Monitoring the client's vital signs closely is crucial during alcohol withdrawal as it helps detect any physiological changes early, such as hypertension, tachycardia, or fever, which can indicate potential complications like delirium tremens. Early identification and prompt intervention can prevent severe outcomes in clients experiencing alcohol withdrawal.

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