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. The nurse documents that a male client with paranoid schizophrenia is delusional. Which statement by the client confirms this assessment?

• A. The voices are telling me to kill the next person I see.
• B. The fire is burning my skin away right now.
• C. The snakes on the wall are going to eat me.
• D. The nurse at night is trying to poison me with pills.

Correct answer: D

Rationale: The correct answer is D. Believing that the nurse is trying to poison him with pills is a clear indication of delusional paranoia, a common symptom in paranoid schizophrenia. Choices A, B, and C do not directly relate to paranoid delusions and are more indicative of hallucinations or other forms of delusions not specific to paranoia.

3. A male client with alcohol dependence is admitted for detoxification. The nurse knows that which assessment finding is indicative of alcohol withdrawal?

• A. Bradycardia
• B. Hypotension
• C. Tremors
• D. Hyperglycemia

Correct answer: C

Rationale: Tremors are a common sign of alcohol withdrawal. The central nervous system becomes hyperexcitable due to the suppression caused by chronic alcohol intake. Tremors are a manifestation of this hyperexcitability and are a key indicator of alcohol withdrawal. Bradycardia and hypotension are more commonly associated with conditions like shock or severe dehydration rather than alcohol withdrawal. Hyperglycemia is not a typical finding in alcohol withdrawal; instead, hypoglycemia is more commonly seen due to the effects of alcohol on glucose metabolism.

4. A client with obsessive-compulsive disorder (OCD) is hospitalized for treatment. Which intervention is most important for the LPN/LVN to include in the client's plan of care?

• A. Allow the client to engage in compulsive behaviors as a way to reduce anxiety.
• B. Encourage the client to ignore the compulsive behaviors.
• C. Help the client to understand the purpose of compulsive behaviors.
• D. Work with the client to gradually reduce the frequency of compulsive behaviors.

Correct answer: D

Rationale: The correct intervention for a client with OCD is to work with them to gradually reduce the frequency of compulsive behaviors. This approach helps the client manage their condition effectively without causing undue distress. Allowing the client to engage in compulsive behaviors can reinforce the disorder rather than alleviate it. Encouraging the client to ignore compulsive behaviors does not address the core issue of OCD. While helping the client understand the purpose of compulsive behaviors can be beneficial, actively working to reduce these behaviors is more crucial in the treatment of OCD.

5. A client with obsessive-compulsive disorder (OCD) repeatedly checks the locks on the doors. What is the most therapeutic nursing intervention?

• A. Allow the client to continue the behavior to reduce anxiety.
• B. Encourage the client to discuss the thoughts and feelings behind the behavior.
• C. Restrict the client's access to the locks.
• D. Schedule specific times for the client to check the locks.

Correct answer: B

Rationale: The most therapeutic nursing intervention for a client with obsessive-compulsive disorder (OCD) who repeatedly checks locks is to encourage the client to discuss the thoughts and feelings behind the behavior. By exploring the underlying anxiety and triggers, the client can work towards understanding and managing their compulsions. Choice A is incorrect because allowing the client to continue the behavior does not address the root cause or help modify the behavior. Choice C is inappropriate as restricting access to locks can increase anxiety and worsen symptoms. Choice D of scheduling specific times for checking locks does not address the underlying psychological issues driving the behavior.

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