Nursing Elites

1. What information should the nurse include in the client's teaching about starting a selective serotonin reuptake inhibitor (SSRI) for major depressive disorder?

• A. It may take several weeks for the medication to take effect.
• B. You can stop taking the medication once you feel better.
• C. Avoid foods high in tyramine while on this medication.
• D. You should expect an immediate improvement in mood.

Correct answer: A

Rationale: The correct answer is A: "It may take several weeks for the medication to take effect." SSRIs typically take several weeks to reach their full effect, and it's important to set realistic expectations for the client. Choice B is incorrect because stopping the medication abruptly can lead to withdrawal symptoms and worsening of depression. Choice C is unrelated to SSRI therapy and pertains more to MAOIs. Choice D is incorrect as SSRIs do not provide immediate improvement in mood; rather, they require time to exert their therapeutic effects.

2. During the manic phase of bipolar disorder, what is the priority nursing intervention for a female client who has not slept for the past 48 hours, is hyperactive, talkative, and engaging in risky behaviors?

• A. Encourage the client to participate in a quiet activity.
• B. Provide a safe environment and limit stimuli.
• C. Administer a sedative to help the client sleep.
• D. Discuss the consequences of her risky behaviors.

Correct answer: B

Rationale: The correct priority nursing intervention for a female client in the manic phase of bipolar disorder, who has not slept for 48 hours, is hyperactive, talkative, and engaging in risky behaviors, is to provide a safe environment and limit stimuli. This approach is crucial to prevent harm to the client and others. Encouraging a quiet activity (Choice A) may not effectively address the need for safety during the manic phase. Administering a sedative (Choice C) should be done under the guidance of a healthcare provider and does not address the immediate safety concerns. Discussing consequences of risky behaviors (Choice D) may not be effective during the manic phase when the client's judgment is impaired.

3. A client is admitted to the psychiatric unit with a diagnosis of bipolar disorder, manic phase. Which activity is most appropriate for the LPN/LVN to suggest to the client?

• A. Playing a game of basketball with other clients.
• B. Taking a walk with the nurse in the garden.
• C. Working on a puzzle in a quiet room.
• D. Writing in a journal.

Correct answer: C

Rationale: During the manic phase of bipolar disorder, individuals may experience heightened levels of energy and agitation. Engaging in activities that are overly stimulating, such as playing basketball with others (choice A) or taking a walk in a garden (choice B), can exacerbate these symptoms. Writing in a journal (choice D) may also be too stimulating and may not provide the necessary distraction. Working on a puzzle in a quiet room (choice C) can offer a calming and focused activity that helps reduce anxiety and channel excess energy into a structured task, making it the most appropriate choice for a client in the manic phase of bipolar disorder.

4. A newly admitted client describes her mission in life as one of saving her son by eliminating the 'provocative sluts' of the world. There are several attractive young women on the unit. What should the LPN/LVN do first?

• A. Ask the client for her definition of 'provocative sluts'
• B. Ask the young female clients on the unit to dress less provocatively
• C. Ask the client to discuss her concerns in the next group session
• D. Ask the client to inform the staff if she has negative thoughts about other clients

Correct answer: D

Rationale: The correct action for the LPN/LVN to take first is to ask the client to inform the staff if she has negative thoughts about other clients. This approach is crucial as it helps in monitoring the client's thoughts and behaviors, potentially preventing any harmful actions towards others on the unit. Asking for the client's definition of 'provocative sluts' (Choice A) may not address the immediate concern of monitoring the client's harmful thoughts. Asking the young female clients to dress less provocatively (Choice B) is inappropriate and victim-blaming. Asking the client to discuss her concerns in the next group session (Choice C) may not be effective in addressing the potential harm the client's thoughts could pose to others on the unit.

5. What is the most therapeutic nursing response for a client with borderline personality disorder who engages in self-mutilating behavior?

• A. Encourage the client to stop hurting themselves.
• B. Discuss what the client was feeling before self-harming.
• C. Inform the client that the behavior will be reported to their doctor.
• D. Ask the client why they hurt themselves.

Correct answer: B

Rationale: The most therapeutic nursing response for a client with borderline personality disorder engaging in self-mutilating behavior is to discuss what the client was feeling before self-harming. This approach helps in exploring the underlying triggers and emotions that lead to self-harm. Option A is directive and may come across as judgmental rather than empathetic. Option C can lead to feelings of betrayal and breach of trust. Option D is a closed-ended question that may not facilitate open communication or exploration of emotions.

Similar Questions