Nursing Elites

1. A client diagnosed with bipolar disorder is experiencing a manic episode. Which of the following actions should the nurse take first?

• A. Encourage the client to participate in group therapy.
• B. Place the client in a private room to decrease stimulation.
• C. Encourage the client to participate in physical activity.
• D. Administer a prescribed sedative.

Correct answer: B

Rationale: During a manic episode, individuals with bipolar disorder may be easily overstimulated. Placing the client in a private room to decrease environmental stimuli is the priority intervention. This action can help reduce the risk of exacerbating manic symptoms and promote a calmer environment for the client. Choice A is not the priority as group therapy may be overwhelming during a manic episode. Choice C could potentially increase stimulation rather than decrease it. Choice D should not be the first action as sedatives are generally not the initial intervention for managing manic episodes.

2. A client states, 'I am the only one who can hear voices.' Which is the nurse's best response?

• A. Tell me more about these voices.
• B. Let's explore these voices together.
• C. How long have you been hearing these voices?
• D. Have you told anyone else about these voices?

Correct answer: A

Rationale: The best response for the nurse is to encourage the client to talk about their experiences with hearing voices. By asking the client to share more details about the voices, the nurse can gain insight into the nature of the auditory hallucinations and better understand the client's condition. This open-ended question allows the client to express themselves freely and helps build rapport and trust between the client and the nurse. Choices B, C, and D do not directly address the client's statement or encourage further elaboration, making them less effective responses in this context.

3. When a patient with major depressive disorder is started on fluoxetine, what is the most important side effect for the nurse to monitor?

• A. Weight gain
• B. Suicidal ideation
• C. Hypertension
• D. Hyperglycemia

Correct answer: B

Rationale: When initiating fluoxetine therapy in a patient with major depressive disorder, monitoring for suicidal ideation is crucial due to the increased risk of suicidal thoughts or behaviors that can occur, especially in the initial phase of treatment. This close monitoring is essential to ensure patient safety and intervene promptly if such symptoms arise. Weight gain, hypertension, and hyperglycemia are potential side effects of some medications used to treat depression, but suicidal ideation is the most critical and immediate side effect to monitor for when starting fluoxetine.

4. A client with borderline personality disorder is receiving care. Which of the following interventions should be included in the plan of care?

• A. Set clear and consistent boundaries
• B. Encourage independence
• C. Avoid discussing the client's feelings
• D. Use a firm, authoritative approach

Correct answer: B

Rationale: When caring for a client with borderline personality disorder, it is essential to encourage independence rather than dependency. This helps promote autonomy and self-reliance, which are important aspects of treatment. Setting clear and consistent boundaries is also crucial, as it provides structure and predictability. Avoiding discussing the client's feelings is not recommended, as addressing emotions and promoting emotional awareness is a key part of therapy. Using a firm, authoritative approach may not be the most effective strategy as it can lead to power struggles and conflicts in individuals with borderline personality disorder.

5. Which of the following interventions is inappropriate for a client experiencing a panic attack?

• A. Provide a well-lit environment.
• B. Encourage deep breathing.
• C. Move the client to a quiet environment.
• D. Administer prescribed antianxiety medication.

Correct answer: A

Rationale: During a panic attack, a well-lit environment might exacerbate the client's symptoms due to sensory overload. Therefore, it is inappropriate to provide a well-lit environment during a panic attack. Encouraging deep breathing, moving the client to a quiet environment, and administering prescribed antianxiety medication are appropriate interventions for managing a panic attack. These actions help create a calming atmosphere and address the physiological symptoms associated with panic attacks.

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