Nursing Elites

1. When developing a plan of care for a male client admitted with delirium tremens, who is dehydrated, experiencing auditory hallucinations, has a bruised, swollen tongue, and is confused, what action should the RN include to ensure the client is physiologically stable?

• A. Encourage oral fluids.
• B. Monitor vital signs.
• C. Keep the room dark.
• D. Apply ice to his tongue.

Correct answer: B

Rationale: Monitoring vital signs is the priority action to ensure the physiological stability of a client with delirium tremens. In this scenario, the client's dehydration, confusion, and other symptoms necessitate close monitoring of vital signs to assess their condition accurately. Encouraging oral fluids (Choice A) is important for hydration but does not directly assess physiological stability. Keeping the room dark (Choice C) may help with hallucinations but is not the primary intervention for physiological stability. Applying ice to the tongue (Choice D) addresses a symptom but is less critical compared to monitoring vital signs in this situation.

2. To provide effective care for a patient diagnosed with schizophrenia, what associated condition should the nurse frequently assess for? Select all that apply.

• A. Alcohol use disorder
• B. Major depressive disorder
• C. Stomach cancer
• D. Polydipsia

Correct answer: A

Rationale: Alcohol use disorder is commonly associated with schizophrenia, leading to a dual diagnosis. Assessing for alcohol use disorder is crucial in managing the patient's overall well-being and treatment plan. Major depressive disorder can co-occur with schizophrenia but is not the most commonly associated condition. Stomach cancer is not typically associated with schizophrenia. Polydipsia, excessive thirst, can be a symptom in some individuals with schizophrenia due to medication side effects, but it is not an associated condition that requires frequent assessment compared to alcohol use disorder.

3. What principle about patient-nurse communication should guide a nurse's fear of 'saying the wrong thing' to a patient?

• A. Patients tend to appreciate a well-meaning person who conveys genuine acceptance, respect, and concern for their situation.
• B. The patient is more interested in talking to you than listening to what you have to say and is not likely to be offended.
• C. Considering the patient's history, there is little chance that the comment will do any actual harm.
• D. Most people with a mental illness have by necessity developed a high tolerance for forgiveness.

Correct answer: A

Rationale: The correct principle guiding nurse-patient communication is that patients value genuine acceptance, respect, and concern. Choice A is the correct answer because showing genuine care and concern for the patient's situation fosters a positive and therapeutic relationship. Choice B is incorrect as effective communication involves active listening and responding appropriately, not assuming the patient is only interested in talking. Choice C is incorrect because a patient's history does not guarantee immunity to harm from inappropriate comments. Choice D is incorrect as it generalizes individuals with mental illness and forgiveness, which is not directly related to communication fears.

4. A client with a history of substance abuse is admitted to the hospital for treatment of a new illness. Which of the following is the most important to assess upon admission?

• A. History of recent drug use.
• B. Current employment status.
• C. Family history of mental illness.
• D. Recent weight changes.

Correct answer: A

Rationale: Assessing the history of recent drug use is crucial when admitting a client with a history of substance abuse. Understanding recent drug use helps in managing potential withdrawal symptoms, preventing drug interactions with the new treatment, and ensuring appropriate care. Assessing current employment status (choice B) is important for social and financial support but is not as crucial as assessing recent drug use in this scenario. Family history of mental illness (choice C) and recent weight changes (choice D) are also important aspects of assessment but are not as immediate and critical as evaluating recent drug use in a client with a history of substance abuse.

5. A client with obsessive-compulsive disorder (OCD) is undergoing behavioral therapy. Which outcome should the nurse recognize as an indication that the client is responding positively to therapy?

• A. The client reports increased frequency of obsessive thoughts.
• B. The client demonstrates a decrease in compulsive behaviors.
• C. The client expresses a desire to leave therapy early.
• D. The client avoids participating in exposure tasks.

Correct answer: B

Rationale: A decrease in compulsive behaviors is a positive response to behavioral therapy for OCD. Behavioral therapy aims to reduce these behaviors and promote healthier coping mechanisms. Option A, reporting an increased frequency of obsessive thoughts, would indicate a lack of improvement or worsening of symptoms. Option C, expressing a desire to leave therapy early, suggests resistance or dissatisfaction with therapy. Option D, avoiding participation in exposure tasks, goes against the principles of exposure therapy, which is commonly used in OCD treatment to help clients confront their fears and reduce anxiety.

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