Nursing Elites

1. A client in the manic phase of bipolar disorder is pacing the hallway and talking rapidly. What is the best intervention for the nurse?

• A. Encourage the client to join a group activity.
• B. Offer the client a high-calorie snack and a drink.
• C. Direct the client to a quieter area of the unit.
• D. Instruct the client to sit down and relax.

Correct answer: B

Rationale: In the manic phase of bipolar disorder, clients often exhibit increased activity and may burn a lot of energy. Offering a high-calorie snack and a drink is the best intervention as it helps maintain their nutritional needs while allowing them to continue their activity. Encouraging the client to join a group activity (Choice A) may further stimulate their behavior. Directing the client to a quieter area (Choice C) might not address their energy expenditure. Instructing the client to sit down and relax (Choice D) may not be effective during the manic phase.

2. A client with obsessive-compulsive disorder (OCD) spends several hours a day washing his hands. What is the most therapeutic nursing intervention?

• A. Allow the client to continue the behavior to reduce anxiety.
• B. Schedule specific times for handwashing.
• C. Encourage the client to discuss the thoughts and feelings behind the behavior.
• D. Restrict the client's access to soap and water.

Correct answer: C

Rationale: Encouraging the client to discuss the thoughts and feelings behind the behavior is the most therapeutic nursing intervention for a client with OCD who excessively washes hands. This approach can help the client understand the underlying reasons for the behavior, address the associated anxiety, and work toward behavior modification. Choices A, allowing the behavior to continue, and D, restricting access to soap and water, do not address the root cause of the behavior and may exacerbate anxiety. Choice B, scheduling specific times for handwashing, does not address the underlying emotional factors contributing to the behavior and may not effectively reduce the client's anxiety.

3. A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of risperidone (Risperdal). When the client walks to the nurse's station in a laterally contracted position, he states that something has made his body contort into a monster. What action should the nurse take?

• A. Medicate the client with the prescribed antipsychotic thioridazine (Mellaril).
• B. Offer the client a prescribed physical therapy hot pack for muscle spasms.
• C. Direct the client to occupational therapy to distract him from somatic complaints.
• D. Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia.

Correct answer: D

Rationale: The correct action for the nurse to take in this situation is to administer the prescribed anticholinergic benztropine (Cogentin) for dystonia. Dystonia can be a side effect of antipsychotic medications like risperidone, leading to involuntary muscle contractions and abnormal postures. Benztropine is an anticholinergic medication commonly used to treat dystonia. Choices A, B, and C are incorrect because thioridazine is not the appropriate medication in this case, a hot pack would not address the underlying issue of dystonia, and occupational therapy is not the primary intervention for addressing acute dystonic reactions.

4. Physical examination of a 6-year-old reveals several bite marks in various locations on his body. X-ray examination reveals healed fractures of the ribs. The mother tells the nurse that her child is always having accidents. Which initial response by the nurse is most appropriate?

• A. I need to inform the healthcare provider about your child's tendency to be accident-prone.
• B. Tell me more specifically about your child's accidents.
• C. I must report these injuries to the authorities because they do not seem accidental.
• D. Boys this age always seem to require more supervision and can be quite accident-prone.

Correct answer: B

Rationale: (B) seeks more information in a non-threatening manner to gather additional details about the child's accidents. This response allows the nurse to explore the situation further without making assumptions. (A) fails to address the concerning findings and instead focuses on informing the healthcare provider. (C) jumps to conclusions without gathering more information, potentially causing unnecessary distress to the family. (D) dismisses the seriousness of the situation by attributing the injuries to common accidents for boys, missing the opportunity to delve deeper into the issue.

5. An elderly client was prescribed Ativan 1 mg three times a day to help calm her anxiety after her husband's death. The next day the client calls her daughter asking when she is picking her up to go to the graveside. The client says she has been walking up and down the driveway for the past hour waiting for her daughter. Noting the client's agitation, hyperactivity, and insistence, the daughter calls the nurse to report her mother's behavior. What should the nurse suspect?

• A. The client is manic and may need a sleeping pill
• B. The client is experiencing a medication interaction and should go to the ED
• C. The client is experiencing a paradoxical reaction to the Ativan and should stop the new medication immediately
• D. The client is overcome by grief and probably needs an antidepressant

Correct answer: C

Rationale: A paradoxical reaction to Ativan, where the drug causes opposite effects such as increased agitation and hyperactivity, should prompt immediate cessation of the medication. In this scenario, the client was prescribed Ativan to help calm her anxiety, but instead, she is displaying symptoms of increased agitation and hyperactivity, indicating a paradoxical reaction. Choice A is incorrect because the symptoms described do not align with mania. Choice B is incorrect as there is no mention of a medication interaction. Choice D is incorrect as the symptoms are more indicative of a paradoxical reaction rather than overwhelming grief.

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