Nursing Elites

1. A client with schizophrenia is experiencing delusions. What is the most appropriate nursing intervention?

• A. Encourage the client to explore the delusions in depth.
• B. Tell the client that the delusions are not real.
• C. Explore the underlying meaning of the delusions.
• D. Distract the client from the delusions and focus on reality.

Correct answer: D

Rationale: The most appropriate nursing intervention for a client with schizophrenia experiencing delusions is to distract the client from the delusions and focus on reality. Encouraging the client to explore the delusions in depth (Choice A) may worsen the delusions. Telling the client that the delusions are not real (Choice B) can lead to confrontation and disbelief. Exploring the underlying meaning of the delusions (Choice C) may not be effective during acute episodes of delusions; hence, distracting the client and refocusing on reality is the most suitable intervention.

2. A client with bipolar disorder is prescribed lithium. What is the most important instruction the nurse should provide?

• A. Avoid foods high in potassium while taking this medication.
• B. Take your medication with food to prevent nausea.
• C. Be sure to maintain a consistent sodium intake.
• D. You can stop taking the medication once your symptoms improve.

Correct answer: C

Rationale: Maintaining a consistent sodium intake is crucial for clients taking lithium because changes in sodium levels can impact lithium concentrations, potentially leading to toxicity. It is essential to avoid excessive sodium intake, as both low and high levels can affect lithium levels. Choices A, B, and D are incorrect. A high potassium diet is not a concern with lithium therapy. While taking lithium with food can help reduce gastrointestinal side effects, it is not the most important instruction. Finally, abruptly stopping lithium can lead to a recurrence of symptoms or a worsening of the condition, so it is vital to follow the prescribed regimen.

3. A client with schizophrenia receiving haloperidol (Haldol) has a stiff, mask-like facial expression and difficulty speaking. What is the nurse's priority action?

• A. Administer a PRN dose of lorazepam (Ativan).
• B. Encourage the client to perform facial exercises.
• C. Notify the healthcare provider of possible extrapyramidal symptoms (EPS).
• D. Document the findings and continue to monitor the client.

Correct answer: C

Rationale: The correct answer is to notify the healthcare provider of possible extrapyramidal symptoms (EPS). The symptoms described, such as a stiff, mask-like facial expression and difficulty speaking, are indicative of EPS, which can be a serious side effect of haloperidol. It is crucial to involve the healthcare provider immediately to address these symptoms. Administering a PRN dose of lorazepam (Choice A) is not the priority in this situation, as it does not address the underlying cause of EPS. Encouraging the client to perform facial exercises (Choice B) is not appropriate and may not effectively manage EPS. Documenting the findings and continuing to monitor the client (Choice D) is important but not the priority when potential EPS is present; immediate action by notifying the healthcare provider is essential.

4. A nurse working in the emergency room of a children's hospital admits a child whose injuries could have resulted from abuse. Which statement most accurately describes the nurse's responsibility in cases of suspected child abuse?

• A. Obtain objective data such as x-rays before reporting suspicions.
• B. Confirm suspicions of abuse with the physician.
• C. Report any case of suspected child abuse.
• D. Document injuries to confirm suspected abuse.

Correct answer: C

Rationale: The correct answer is C: 'Report any case of suspected child abuse.' Nurses are mandated reporters, which means they are legally obligated to report any suspicions of child abuse to appropriate authorities to ensure the child's safety. This responsibility overrides the need to gather additional data or confirm suspicions with others before reporting. Choice A is incorrect because delaying reporting to gather more data may risk the child's safety. Choice B is incorrect because reporting suspicions promptly is crucial, and waiting to confirm with another healthcare provider could delay necessary intervention. Choice D is incorrect as the priority is to report suspicions promptly rather than focusing on documenting injuries to confirm abuse.

5. A client with obsessive-compulsive disorder (OCD) spends several hours a day arranging and rearranging items in their room. What is the most therapeutic nursing intervention?

• A. Distract the client with another activity.
• B. Allow the client to continue the behavior.
• C. Set a time limit for the behavior.
• D. Encourage the client to verbalize their feelings.

Correct answer: D

Rationale: Encouraging the client to verbalize their feelings is the most therapeutic intervention for a client with OCD spending excessive time on compulsive behaviors. By expressing their feelings, the client can explore the underlying anxiety that drives the compulsion. This intervention also provides an opportunity for the nurse to offer support and help the client develop coping strategies.\n Choice A, distracting the client with another activity, may provide temporary relief but does not address the root cause of the behavior.\n Choice B, allowing the client to continue the behavior, does not promote therapeutic progress and may perpetuate the compulsion.\n Choice C, setting a time limit for the behavior, may create additional stress for the client and does not address the underlying emotional issues associated with OCD.

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