Nursing Elites

1. A male client with known auditory hallucinations begins talking loudly and gesturing wildly while in the unit’s day room. What action should the nurse implement first?

• A. Administer a PRN sedative.
• B. Sit in the chair next to the client.
• C. Escort the client to his room.
• D. Listen to what the client is saying.

Correct answer: D

Rationale: When dealing with a client experiencing auditory hallucinations, it is crucial for the nurse to first listen to what the client is saying. Auditory hallucinations may hold significance to the client, and by actively listening, the nurse can gather information about the content and context of the hallucinations. This information helps the nurse assess the client's current state, emotional responses, and the potential triggers for the behavior. Administering a PRN sedative (Choice A) should not be the initial action as it may suppress important information and feelings the client is trying to communicate. Sitting next to the client (Choice B) may not be appropriate without understanding the situation better. Escorting the client to his room (Choice C) may escalate the situation without addressing the underlying cause of the behavior, which can be better understood through active listening.

2. The RN is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. Which strategies should be included in the safety plan? (SOA)

• A. Purchase a gun for protection.
• B. Establish a code with family and friends to signal violence.
• C. Take a self-defense course focused on protection.
• D. Prepare a bag with extra clothes for self and children.

Correct answer: B

Rationale: Establishing a code with family and friends is crucial in situations of intimate partner violence as it allows discreet communication for help without alerting the abuser. Having a pre-prepared bag with essentials like extra clothes is important to facilitate a quick exit if necessary. Purchasing a gun is not a recommended safety strategy as it can escalate violence and pose more danger. While taking a self-defense course focused on protection is beneficial, it is essential to avoid courses that emphasize retaliation, as they can increase the risk and escalate violence.

3. A client with major depressive disorder is prescribed lithium carbonate. Which finding should the RN report to the healthcare provider?

• A. Serum lithium level of 0.8 mEq/L
• B. Blood urea nitrogen (BUN) level of 16 mg/dL
• C. Serum sodium level of 138 mEq/L
• D. Urine output of 800 mL in 24 hours

Correct answer: B

Rationale: The correct answer is B. Elevated BUN levels may indicate renal impairment, which is crucial to report for clients on lithium due to its potential kidney effects. Option A, a serum lithium level of 0.8 mEq/L, is within the therapeutic range for lithium and does not require immediate reporting. Option C, a serum sodium level of 138 mEq/L, is within the normal range and not directly related to lithium therapy. Option D, urine output of 800 mL in 24 hours, may indicate a need for further assessment but is not the most critical finding to report compared to potential renal impairment indicated by an elevated BUN level.

4. When preparing to administer a domestic violence screening tool to a female client, which statement should the RN provide?

• A. If you are experiencing abuse from your partner, I am required to ask you these questions.
• B. It is a requirement by law for me to inquire if you are a victim of domestic violence.
• C. Your healthcare provider must be informed if you are facing any domestic abuse.
• D. All clients undergo screening for domestic abuse due to its prevalence in our society.

Correct answer: D

Rationale: The correct answer is D because screening all clients for domestic abuse as a routine part of care helps in early identification and support. Choice A is incorrect as it may imply that the questions are only asked if abuse is already suspected. Choice B is incorrect because it emphasizes the legal obligation rather than the importance of routine screening. Choice C is incorrect as it focuses on the healthcare provider's need rather than the benefit to the client of routine screening.

5. A client who is known to abuse drugs is admitted to the psychiatric unit. Which medication should the nurse anticipate administering to a client who is exhibiting benzodiazepine withdrawal symptoms?

• A. Diphenhydramine (Benadryl)
• B. Perphenazine (Trilafon)
• C. Isocarboxazid (Marplan)
• D. Chlordiazepoxide (Librium)

Correct answer: D

Rationale: Chlordiazepoxide (Librium) is the correct choice for managing benzodiazepine withdrawal symptoms. Benzodiazepines are drugs that can lead to physical dependence, and abrupt discontinuation can result in withdrawal symptoms. Chlordiazepoxide, a benzodiazepine itself, is often used in a controlled manner to taper off the drug gradually and manage withdrawal symptoms effectively. Choices A, Diphenhydramine, and B, Perphenazine, are not typically used to manage benzodiazepine withdrawal. Choice C, Isocarboxazid, is a monoamine oxidase inhibitor (MAOI) used in the treatment of depression and not indicated for benzodiazepine withdrawal.

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