Nursing Elites

1. A male client is admitted to the mental health unit because he was feeling depressed about the loss of his wife and job. The client has a history of alcohol dependency and admits that he was drinking alcohol 12 hours ago. Vital signs are: temperature, 100 F, pulse 100, and BP 142/100. The nurse plans to give the client lorazepam (Ativan) based on which priority nursing diagnosis?

• A. Risk for injury related to suicidal ideation.
• B. Risk for injury related to alcohol detoxification.
• C. Knowledge deficit related to ineffective coping.
• D. Health-seeking behaviors related to personal crisis.

Correct answer: B

Rationale: The most important nursing diagnosis is related to alcohol detoxification (B) because the client has elevated vital signs, a sign of alcohol detoxification. Giving lorazepam (Ativan) to address the elevated vital signs due to alcohol withdrawal is a priority. Addressing the risk for injury related to suicidal ideation (A) should come after stabilizing the client's physiological state. Both (C) and (D) can be addressed once immediate safety needs are met, but the priority is managing the alcohol detoxification to prevent potential complications.

2. A nurse is caring for a client who is experiencing withdrawal symptoms from opioid addiction. What is the priority nursing intervention?

• A. Monitor for signs of respiratory depression.
• B. Administer methadone as prescribed.
• C. Provide a calm and quiet environment.
• D. Encourage fluid intake to prevent dehydration.

Correct answer: A

Rationale: The correct answer is A: Monitor for signs of respiratory depression. During opioid withdrawal, the priority is to monitor the client for respiratory depression as it can be life-threatening. Respiratory depression is a serious concern during opioid withdrawal, and prompt recognition and intervention are crucial. Administering methadone as prescribed (Choice B) may be part of the treatment plan but is not the priority in this situation. Providing a calm and quiet environment (Choice C) and encouraging fluid intake to prevent dehydration (Choice D) are important aspects of care but do not take precedence over monitoring for respiratory depression.

3. 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.

4. A client with panic disorder is prescribed sertraline (Zoloft). What is the most important information for the nurse to provide?

• A. You should take this medication at the same time every day.
• B. It may take several weeks for you to feel the full effect.
• C. This medication may cause a significant increase in appetite.
• D. You may experience dizziness, so avoid driving.

Correct answer: B

Rationale: The correct answer is B. SSRIs like sertraline may take several weeks to reach their full therapeutic effect, so it's important to inform the client to be patient with the treatment. Choice A is not the most crucial information regarding sertraline. Choice C is not a common side effect of sertraline. Choice D is important but not as crucial as informing about the delayed onset of action.

5. A client with a history of bipolar disorder presents to the emergency department with symptoms of mania. What is the priority nursing intervention?

• A. Administer prescribed medication to manage symptoms.
• B. Provide a calm environment with minimal stimulation.
• C. Encourage the client to express feelings and emotions.
• D. Reinforce the need for consistent medication adherence.

Correct answer: A

Rationale: Administering prescribed medication to manage symptoms is the priority intervention for a client with symptoms of mania. During a manic episode, the client may be at risk of harm to self or others due to impulsivity and poor judgment. Medication helps stabilize the client, reduce manic symptoms, and prevent further escalation. Providing a calm environment (choice B) is important but not the priority when the client's safety is at risk. Encouraging expression of feelings (choice C) and reinforcing medication adherence (choice D) are valuable aspects of care but addressing the acute symptoms of mania takes precedence to ensure the client's immediate safety and well-being.

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