Nursing Elites

1. A female client refuses to take an oral hypoglycemic agent because she believes that the drug is being administered as part of an elaborate plan by the Mafia to harm her. Which nursing intervention is most important to include in this client's plan of care?

• A. Reassure the client that no one will harm her while she is in the hospital.
• B. Ask the healthcare provider to give the client the medication.
• C. Explain the importance of taking the diabetic medication.
• D. Reassess the client's mental status for thought processes and content.

Correct answer: D

Rationale: Reassessing the client's mental status is the most important intervention as it is crucial to address the client's delusional thinking. By assessing the client's thought processes and content, the nurse can gain insight into the client's beliefs and tailor interventions accordingly. Reassuring the client that no harm will come to her, asking the healthcare provider to give the medication, or simply explaining the importance of taking the medication may not effectively address the underlying issue of delusional beliefs.

2. A male client with alcohol use disorder is admitted for detoxification. The nurse knows that which symptom is a sign of severe alcohol withdrawal?

• A. Bradycardia
• B. Seizures
• C. Hyperglycemia
• D. Constipation

Correct answer: B

Rationale: Seizures are a sign of severe alcohol withdrawal and can be life-threatening, requiring immediate medical attention. Bradycardia, hyperglycemia, and constipation are not typically associated with severe alcohol withdrawal. Bradycardia is more commonly seen in opioid withdrawal, hyperglycemia could be due to other reasons like uncontrolled diabetes, and constipation is not a typical symptom of severe alcohol withdrawal.

3. A client with schizophrenia is prescribed olanzapine (Zyprexa). What is the most important side effect for the nurse to monitor?

• A. Hypotension
• B. Weight gain
• C. Dry mouth
• D. Tachycardia

Correct answer: B

Rationale: The correct answer is B: Weight gain. Olanzapine (Zyprexa) is known to cause significant weight gain in patients. This side effect is crucial to monitor because it can lead to metabolic syndrome, diabetes, and cardiovascular issues. Monitoring the client's weight regularly and providing appropriate dietary guidance is essential. Hypotension (choice A), dry mouth (choice C), and tachycardia (choice D) are not commonly associated with olanzapine use and are not the primary side effects to monitor in this case.

4. A male client with schizophrenia who is taking fluphenazine decanoate (Prolixin decanoate) is being discharged in the morning. A repeat dose of medication is scheduled for 20 days after discharge. The client tells the nurse that he is going on vacation in the Bahamas and will return in 18 days. Which statement by the client indicates a need for health teaching?

• A. "When I return from my tropical island vacation, I will go to the clinic to get my Prolixin injection."
• B. "While I am on vacation and when I return, I will not consume any alcohol-containing food or beverages."
• C. "I will inform the healthcare provider if I develop a sore throat or flu-like symptoms."
• D. "I will maintain my daily intake of benztropine mesylate (Cogentin)."

Correct answer: A

Rationale: Photosensitivity is a side effect of Prolixin, and a vacation in the Bahamas (with its tropical island climate) increases the client's risk of experiencing this side effect. Therefore, the client should be advised to avoid direct sun exposure. Choice A indicates a need for health teaching as the client plans to return from vacation in 18 days, which is earlier than the scheduled dose of Prolixin at 20 days after discharge. Choices B, C, and D demonstrate accurate knowledge. Choice B is important because alcohol can interact with Prolixin. Choice C is relevant as it mentions signs of agranulocytosis, a potential side effect of Prolixin. Choice D is correct as benztropine mesylate is used to prevent extrapyramidal symptoms associated with Prolixin.

5. A male client with mental illness and substance dependency tells the mental health nurse that he has started using illegal drugs again and wants to seek treatment. Since he has a dual diagnosis, which person is best for the nurse to refer this client to first?

• A. The emergency room nurse.
• B. His case manager.
• C. The clinic healthcare provider.
• D. His support group sponsor.

Correct answer: B

Rationale: The case manager (B) is responsible for coordinating community services, making them the best person to refer the client to first as they can describe available treatment options. The emergency room nurse (A) is unnecessary unless the client's behaviors pose imminent threats. The clinic healthcare provider (C) and support group sponsor (D) may be useful but coordinating a treatment program tailored to the client's needs is the priority in this scenario.

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