Nursing Elites

1. A client with major depressive disorder is prescribed a selective serotonin reuptake inhibitor (SSRI). Which side effect should the nurse educate the client about?

• A. Hypertension.
• B. Sexual dysfunction.
• C. Increased appetite.
• D. Weight gain.

Correct answer: B

Rationale: The correct answer is B: Sexual dysfunction. Sexual dysfunction is a common side effect of SSRIs. While hypertension (A) can occur with other medications, it is not typically associated with SSRIs. Increased appetite (C) and weight gain (D) are potential side effects of some antidepressants, but sexual dysfunction is more specific to SSRIs. Therefore, the nurse should educate the client about the risk of sexual dysfunction when taking an SSRI.

2. A client, who is on a 30-day commitment to a drug rehabilitation unit, asks the nurse if he can go for a walk on the grounds of the treatment center. When he is told that his privileges do not include walking on the grounds, the client becomes verbally abusive. Which approach will the nurse take?

• A. Call a staff member to escort the client to his room.
• B. Tell the client to talk to his healthcare provider about his privileges.
• C. Remind the client of the unit rules.
• D. Ignore the client's inappropriate behavior.

Correct answer: C

Rationale: (C) is the correct approach in this situation as it reinforces unit rules, setting clear boundaries and expectations. By reminding the client of the unit rules, the nurse is helping to maintain a safe and structured environment within the drug rehabilitation unit. (A) is unnecessary since the client's behavior does not warrant immediate physical intervention. (B) is not ideal because the client's privileges have already been explained, and suggesting he speak to his healthcare provider may not address the immediate issue. (D) is not appropriate as addressing inappropriate behavior is essential in a therapeutic setting.

3. The wife of a client diagnosed with paranoid schizophrenia visits 2 days after her husband's admission and states to the nurse, 'Why isn't he eating? He's still talking about his food being poisoned.' Which of the following appraisals by the LPN/LVN is most accurate?

• A. The wife's inquiry is reasonable.
• B. Education about her husband's medication is needed.
• C. Her expectations of her husband are realistic.
• D. An increase in the client's medication is needed.

Correct answer: B

Rationale: The correct answer is B. The wife needs education about her husband's medication to understand how it affects his perceptions, including paranoid thoughts about food. Choice A is incorrect because the wife's inquiry reflects her lack of understanding of the situation rather than being reasonable. Choice C is incorrect as the husband's condition requires specialized care beyond what the wife might consider realistic. Choice D is incorrect as increasing medication should not be the immediate response; education and reassurance are key in this situation.

4. A young adult male client, diagnosed with paranoid schizophrenia, believes that the world is trying to poison him. What intervention should the nurse include in this client's plan of care?

• A. Remind the client that his suspicions are not true.
• B. Ask one nurse to spend time with the client daily.
• C. Encourage the client to participate in group activities.
• D. Assign the client to a room closest to the activity room.

Correct answer: B

Rationale: A client with paranoid schizophrenia has difficulty with trust and developing a trusting relationship with one nurse (B) is likely to be therapeutic for this client. Choice (A) is argumentative and may increase the client's resistance. Choice (C) might be too overwhelming and anxiety-provoking for the client. Choice (D) could increase the client's stress and anxiety, which are counterproductive in managing paranoid ideations.

5. An LPN/LVN is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented that the client is experiencing anxiety as a result of a situational crisis. The nurse determines that this type of crisis is caused by:

• A. Witnessing a murder
• B. The death of a loved one
• C. A fire that destroyed the client's home
• D. A recent rape episode experienced by the client

Correct answer: B

Rationale: The correct answer is B: 'The death of a loved one.' A situational crisis, like the death of a loved one, can lead to anxiety due to a significant change or loss in the person's life. Choices A, C, and D involve traumatic events, but a situational crisis typically refers to life events that disrupt an individual's normal pattern of living, such as the death of a loved one.

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