Nursing Elites

1. A client is on a methadone maintenance program for opioid addiction. What is the most important assessment to perform?

• A. Monitor for signs of withdrawal.
• B. Assess for signs of methadone toxicity.
• C. Evaluate the client's respiratory status.
• D. Check the client's blood pressure regularly.

Correct answer: C

Rationale: The most important assessment to perform for a client on a methadone maintenance program is to evaluate the client's respiratory status. Methadone can cause respiratory depression as a side effect, making it crucial to monitor the client's breathing to prevent potential complications. Monitoring for signs of withdrawal (choice A) is important but not the most critical in this scenario. Assessing for signs of methadone toxicity (choice B) is relevant, but respiratory status takes precedence due to the risk of respiratory depression. Checking the client's blood pressure regularly (choice D) is important for overall assessment but is not as crucial as monitoring respiratory status in this case.

2. A client with alcohol use disorder is admitted for detoxification. The nurse should monitor for which early sign of alcohol withdrawal?

• A. Seizures
• B. Visual hallucinations
• C. Tremors
• D. Delirium tremens

Correct answer: C

Rationale: Tremors are an early sign of alcohol withdrawal. They are caused by hyperactivity of the autonomic nervous system and are a common symptom during the early stages of withdrawal. Monitoring tremors is crucial as they can progress to more severe symptoms if not managed effectively. Seizures (Choice A) typically occur later in the withdrawal process and are a more severe symptom. Visual hallucinations (Choice B) usually manifest after tremors and are considered a mid-stage symptom. Delirium tremens (Choice D) is a severe form of alcohol withdrawal that typically occurs 2-3 days after the last drink, characterized by confusion, disorientation, and severe autonomic hyperactivity.

3. An older female adult who lives in a nursing home is loudly demanding that the nurse call her son who has been deceased for five years. Which intervention should the nurse implement?

• A. Assist the client in making the phone call.
• B. Remind the client about her son's passing.
• C. Escort the client to a private area.
• D. Direct the client to a new activity.

Correct answer: D

Rationale: In this situation, the most appropriate intervention is to direct the client to a new activity. This approach can help redirect the client's attention, distract her from the distressing request, and engage her in a more positive interaction. Choice A could exacerbate the client's distress by attempting to make the impossible call, and reminding the client about her son's passing (Choice B) may increase her emotional distress. Escorting the client to a private area (Choice C) does not address the underlying issue and may not effectively manage the situation.

4. Which action should the nurse implement during the termination phase of the nurse-client relationship?

• A. Identify new problem areas.
• B. Confront changes not completed.
• C. Explore the client's past in depth.
• D. Help summarize accomplishments.

Correct answer: D

Rationale: During the termination phase of the nurse-client relationship, it is essential for the nurse to help summarize accomplishments. This action provides closure by reflecting on the progress and goals achieved during treatment. It reinforces the positive aspects of the therapeutic relationship and helps the client acknowledge their growth and achievements. Choices A, B, and C are incorrect. Identifying new problem areas is not appropriate during termination, as the focus should be on closure. Confronting changes not completed may create tension and disrupt the positive closure process. Exploring the client's past in depth is more suitable for earlier stages of the therapeutic relationship, not during termination.

5. A client with borderline personality disorder tells the nurse, 'You're the only one who understands me. The other nurses don't care about me.' Which response by the nurse is most appropriate?

• A. Why do you feel that way about the other nurses?
• B. The other nurses care about you too.
• C. I am here to help you just like the other nurses.
• D. Let's talk about why you feel this way.

Correct answer: C

Rationale: The most appropriate response is 'I am here to help you just like the other nurses' (C). This response sets boundaries and avoids reinforcing the client's splitting behavior, which is common in borderline personality disorder. Choices A and D may unintentionally reinforce the splitting by focusing on the negative perception of other nurses. Choice B might be perceived as dismissive because it contradicts the client's feelings of being understood only by the nurse.

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