Nursing Elites

1. A female client on a psychiatric unit is sweating profusely while vigorously doing push-ups and then running the length of the corridor several times before crashing into furniture in the sitting room. Picking herself up, she begins to verbally attack other clients. What intervention is most appropriate for the RN to use to manage the client’s behavior?

• A. Assist the client to a safe area to avoid injury.
• B. Establish clear and firm limits with the client.
• C. Offer medication to help calm the client down.
• D. Speak with the client in a calm, non-threatening manner.

Correct answer: A

Rationale: Assisting the client to a safe area is the most appropriate intervention in this scenario. This action helps prevent injury to the client and others while allowing for de-escalation in a controlled environment. While establishing clear and firm limits (Choice B) may be necessary in some situations, the immediate priority here is safety. Offering medication (Choice C) should not be the first response unless the situation escalates further and poses a risk to the client or others. Speaking with the client in a calm, non-threatening manner (Choice D) may not be effective when the client is in an agitated state and engaging in risky behavior.

2. A client who recently experienced the death of a significant other arrives at the mental health center. The client reports loss of interest in usual activities, expresses a wish to be with the deceased significant other, has been eating very little, and has not slept in several days. Which client statement is most important for the RN to explore at this time?

• A. Not sleeping for several days.
• B. Wishing to be with the deceased significant other.
• C. Lack of interest in usual activities.
• D. Eating very little.

Correct answer: A

Rationale: The most important client statement for the RN to explore in this scenario is the client not sleeping for several days. The lack of sleep is a critical indicator of possible severe depression or suicidal ideation that requires immediate attention. While expressing a wish to be with the deceased significant other, having a lack of interest in usual activities, and eating very little are concerning, the immediate focus should be on the client's severe sleep disturbance as it can pose an immediate risk to their well-being and safety.

3. A client with a diagnosis of schizophrenia is exhibiting negative symptoms such as anhedonia and social withdrawal. Which intervention should be a priority for the nurse?

• A. Encourage participation in group activities.
• B. Administer prescribed antipsychotic medication.
• C. Assist the client in setting realistic goals.
• D. Promote engagement in social interactions.

Correct answer: A

Rationale: Encouraging participation in group activities is a priority intervention for a client with schizophrenia exhibiting negative symptoms like anhedonia and social withdrawal. Group activities provide structured social interactions and can help the client gradually re-engage with others, potentially reducing social withdrawal and improving social skills. Administering antipsychotic medication (Choice B) is essential in managing positive symptoms of schizophrenia such as hallucinations and delusions, not negative symptoms like anhedonia and social withdrawal. While assisting the client in setting realistic goals (Choice C) is important for overall care, addressing social withdrawal and anhedonia is more immediate. Promoting engagement in social interactions (Choice D) is beneficial, but encouraging participation in group activities provides a structured and supportive environment that can specifically target the negative symptoms being exhibited.

4. A male adult is admitted because of an acetaminophen (Tylenol) overdose. After transfer to the mental health unit, the client is told he has liver damage. Which information is most important for the nurse to include in the client’s discharge plan?

• A. Eat a high-carbohydrate, low-fat, low-protein diet.
• B. Do not take any over-the-counter medication.
• C. Call the crisis hotline if feeling lonely.
• D. Avoid exposure to large crowds.

Correct answer: B

Rationale: The most important information for the nurse to include in the client’s discharge plan is to not take any over-the-counter medication. This is crucial because over-the-counter medications can potentially interact with the damaged liver and worsen the condition. Choices A, C, and D are not as critical in the context of liver damage from an acetaminophen overdose. While diet is important for overall health, specifically for liver damage, avoiding over-the-counter medications takes precedence. Calling the crisis hotline for loneliness and avoiding exposure to large crowds are important considerations but are not directly related to the client's liver damage from the acetaminophen overdose.

5. The nurse is assessing a client who has schizophrenia and is exhibiting symptoms of paranoia. Which behavior would the nurse most likely observe?

• A. The client is seen as unmotivated and withdrawn.
• B. The client is preoccupied with a fear of being harmed.
• C. The client displays a blunted affect and lacks emotional response.
• D. The client avoids group activities and shows decreased appetite.

Correct answer: B

Rationale: In clients with paranoia, they typically exhibit an intense fear of being harmed, persecuted, or targeted by others. This fear often dominates their thoughts and can significantly impact their daily functioning and interactions. Choice A, being unmotivated and withdrawn, is more indicative of negative symptoms of schizophrenia, such as avolition and social withdrawal. Choice C, displaying a blunted affect and lacking emotional response, is associated with flat affect, a symptom commonly seen in schizophrenia but not specific to paranoia. Choice D, avoiding group activities and showing decreased appetite, may be related to various symptoms or side effects, but it is not a defining characteristic of paranoia in schizophrenia.

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