Nursing Elites

1. A male client with delirium becomes disoriented and confused in his room at night. The best initial nursing intervention is to:

• A. Move the client next to the nurse's station
• B. Use an indirect light source and turn off the television
• C. Keep the television and a soft light on during the night
• D. Play soft music during the night, and maintain a well-lit room

Correct answer: B

Rationale: The best initial nursing intervention for a male client with delirium who becomes disoriented and confused in his room at night is to use an indirect light source and turn off the television. This approach helps to reduce stimulation and confusion, aiding in the client's orientation and comfort. Moving the client next to the nurse's station (Choice A) may not address the root cause of disorientation and could disrupt the client's routine. Keeping the television and a soft light on (Choice C) may further contribute to the client's confusion. Playing soft music and maintaining a well-lit room (Choice D) may not be as effective in reducing stimulation and promoting orientation as using an indirect light source and turning off the television.

2. The nurse is performing intake interviews at a psychiatric clinic. A female client with a known history of drug abuse reports that she had a heart attack four years ago. Use of which substance abuse places the client at the highest risk for myocardial infarction?

• A. Benzodiazepines
• B. Marijuana
• C. Methamphetamine
• D. Alcohol

Correct answer: C

Rationale: Methamphetamine use is strongly associated with cardiovascular risks, including myocardial infarction, due to its stimulant effects on the heart. Benzodiazepines (Choice A) are not typically associated with an increased risk of myocardial infarction. Marijuana (Choice B) is not commonly linked to heart attacks, though it can have other health effects. Alcohol (Choice D) abuse can lead to cardiovascular issues, but methamphetamine has a more direct and potent impact on the heart, making it the highest risk factor in this scenario.

3. For a female client with major depressive disorder reporting feelings of hopelessness and helplessness, what is the nurse's priority intervention?

• A. Encourage the client to join a support group.
• B. Refer the client for cognitive-behavioral therapy (CBT).
• C. Assess the client's risk for suicide.
• D. Suggest the client participate in daily exercise.

Correct answer: C

Rationale: The correct answer is to assess the client's risk for suicide. When a client expresses feelings of hopelessness and helplessness, it indicates a high risk of self-harm or suicide. Therefore, the priority intervention should be to assess the client's safety. Encouraging the client to join a support group (choice A) may be beneficial but not the priority at this time. Referring the client for cognitive-behavioral therapy (CBT) (choice B) and suggesting daily exercise (choice D) are important interventions in managing depression but assessing the risk for suicide takes precedence due to the immediate safety concern.

4. A client with schizophrenia is admitted to the psychiatric care unit for aggressive behavior, auditory hallucinations, and potential for self-harm. The client has not been taking medications as prescribed and insists that the food has been poisoned and refuses to eat. What intervention should the RN implement?

• A. Assure the client that all food served in the hospital is safe to eat.
• B. Tell the client that irrational thinking is a symptom of schizophrenia.
• C. Obtain an order for a tube feeding for the client.
• D. Provide the client with food in unopened containers.

Correct answer: D

Rationale: The correct intervention is to provide the client with food in unopened containers. This approach can help alleviate the client's fear of poisoning and encourage eating. Choice A may not address the client's specific fear and may be perceived as dismissive. Choice B, while providing information about symptoms of schizophrenia, does not address the immediate issue of the client's refusal to eat due to the fear of poisoning. Choice C of obtaining an order for tube feeding is premature and invasive before exploring less restrictive options.

5. When developing a plan of care for a client in the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing diagnosis has the highest priority?

• A. Risk for injury.
• B. Ineffective coping mechanisms.
• C. Alteration in comfort.
• D. Ineffective breathing patterns.

Correct answer: D

Rationale: When a client aspirates a caustic material, the priority nursing diagnosis should focus on addressing physiological concerns, particularly related to breathing patterns. Aspiration of caustic material can lead to airway compromise, respiratory distress, and potential lung damage. Therefore, monitoring and addressing ineffective breathing patterns are crucial for ensuring the client's immediate safety and well-being. Choices A, B, and C are important considerations in psychiatric care but are secondary to the critical physiological issue of ineffective breathing patterns in this scenario.

Similar Questions