Nursing Elites

1. In observing a client who is pacing, agitated, and presenting aggressive gestures, with rapid speech pattern and belligerent affect, what is the immediate priority of care for the nurse?

• A. Provide safety for the client and other clients on the unit
• B. Provide the clients on the unit with a sense of comfort and safety
• C. Assist the staff in caring for the client in a controlled environment
• D. Offer the client a less stimulated area to calm down and gain control

Correct answer: A

Rationale: In a situation where a client is displaying aggression and agitation, the immediate priority of care for the nurse is to ensure safety for the client and others on the unit. Providing a safe environment and implementing calming measures take precedence over other interventions. Option A is the correct choice as it addresses the crucial need for safety in a potentially volatile situation. Options B, C, and D, although important, do not address the primary concern of ensuring safety for all individuals involved.

2. A nurse is assessing a client with generalized anxiety disorder (GAD) who reports difficulty concentrating and feeling restless. What is the most appropriate nursing intervention?

• A. Encourage the client to avoid caffeine.
• B. Suggest the client take up a new hobby.
• C. Teach the client deep breathing exercises.
• D. Refer the client to group therapy.

Correct answer: C

Rationale: Teaching deep breathing exercises is the most appropriate intervention for a client with generalized anxiety disorder (GAD) experiencing difficulty concentrating and restlessness. Deep breathing exercises are a proven technique to help manage anxiety symptoms, promote relaxation, and improve concentration. Encouraging the client to avoid caffeine (Choice A) may be beneficial, but it is not the most direct intervention for the reported symptoms. Suggesting the client take up a new hobby (Choice B) may be helpful for overall well-being but does not directly address the immediate symptoms. Referring the client to group therapy (Choice D) may be beneficial in the long term, but teaching deep breathing exercises is more immediate and can be easily implemented by the client in various settings.

3. A nurse is caring for a client who is experiencing severe anxiety. Which intervention is most appropriate for the nurse to implement?

• A. Instruct the client to take deep breaths and focus on the present.
• B. Encourage the client to discuss their fears in detail.
• C. Distract the client with a humorous story or anecdote.
• D. Leave the client alone to process their emotions.

Correct answer: A

Rationale: The correct intervention for a client experiencing severe anxiety is to instruct the client to take deep breaths and focus on the present. Deep breathing can help reduce the physiological symptoms of anxiety and provide the client with a way to regain control over their emotions. Choice B is incorrect as discussing fears in detail may escalate anxiety levels. Choice C is inappropriate as distracting the client may not address the root cause of anxiety. Choice D is not recommended as leaving the client alone can increase feelings of isolation and distress.

4. A client with a diagnosis of major depressive disorder is prescribed fluoxetine (Prozac). What is the most important side effect for the LPN/LVN to monitor?

• A. Weight gain.
• B. Sexual dysfunction.
• C. Nausea.
• D. Constipation.

Correct answer: B

Rationale: The correct answer is B: Sexual dysfunction. When monitoring a client taking fluoxetine (Prozac), the LPN/LVN should prioritize observing for sexual dysfunction. This side effect is crucial to monitor as it can significantly impact the client's quality of life and may affect their adherence to the medication. Weight gain (choice A) is a possible side effect of fluoxetine but is not as critical as sexual dysfunction in terms of monitoring. Nausea (choice C) and constipation (choice D) are common side effects of fluoxetine, but they are generally less concerning compared to the impact of sexual dysfunction on the client's well-being and treatment compliance.

5. A female client with severe depression who has been on antidepressants for two weeks suddenly becomes more energetic and talkative. What action should the RN take first?

• A. Encourage the client to participate in group activities.
• B. Monitor the client closely for signs of suicidal behavior.
• C. Praise the client for the apparent improvement.
• D. Discuss the client's progress with the healthcare provider.

Correct answer: B

Rationale: A sudden increase in energy and talkativeness in a client with severe depression who has been on antidepressants for a short period may indicate an increased risk of suicide due to the potential shift from profound sadness to motivation to act. The first action the RN should take is to monitor the client closely for signs of suicidal behavior. Encouraging participation in group activities or praising the client for the apparent improvement may overlook the potential risk of suicidal behavior. While discussing the client's progress with the healthcare provider is important, the immediate concern is to ensure the client's safety by closely monitoring for any signs of suicidal ideation or behavior.

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