Nursing Elites

1. A client with depression reports difficulty sleeping. What is the most appropriate nursing intervention?

• A. Encourage the client to take short naps during the day.
• B. Suggest the client drink a warm beverage before bedtime.
• C. Recommend the client exercise immediately before bedtime.
• D. Advise the client to take a sleep aid nightly.

Correct answer: B

Rationale: The most appropriate nursing intervention for a client with depression reporting difficulty sleeping is to suggest the client drink a warm beverage before bedtime. A warm beverage can promote relaxation and help establish a bedtime routine, which may aid in improving sleep quality. Encouraging short naps during the day (Choice A) may disrupt the client's nighttime sleep pattern. Recommending exercise immediately before bedtime (Choice C) can have a stimulating effect, making it harder for the client to fall asleep. Advising the client to take a sleep aid nightly (Choice D) should only be considered after other non-pharmacological interventions have been attempted and in consultation with a healthcare provider due to potential side effects and risks associated with sleep aids.

2. A female client with post-traumatic stress disorder (PTSD) has been experiencing flashbacks. Which intervention should the nurse implement to help the client?

• A. Encourage the client to talk about the trauma.
• B. Advise the client to avoid triggers that cause flashbacks.
• C. Help the client stay grounded in the present moment.
• D. Refer the client to group therapy for PTSD.

Correct answer: C

Rationale: The correct intervention for a client with PTSD experiencing flashbacks is to help them stay grounded in the present moment. This technique can reduce the intensity of flashbacks and provide a sense of safety. Encouraging the client to talk about the trauma (Choice A) may exacerbate the symptoms and should be done cautiously under professional guidance. Advising the client to avoid triggers (Choice B) is important, but solely relying on avoidance may not address the underlying issues. Referring the client to group therapy (Choice D) can be beneficial, but in the immediate context of managing flashbacks, grounding techniques are more appropriate.

3. A client with schizophrenia is being discharged with a prescription for risperidone (Risperdal). What is the most important information for the nurse to provide?

• A. You need to have regular blood tests while taking this medication.
• B. Report any muscle stiffness or unusual movements immediately.
• C. Avoid foods high in tyramine while taking this medication.
• D. This medication may cause weight loss.

Correct answer: B

Rationale: The correct answer is B: "Report any muscle stiffness or unusual movements immediately." This information is crucial because muscle stiffness or unusual movements may indicate extrapyramidal symptoms (EPS), a potential side effect of risperidone that requires immediate attention. Choice A is less critical as regular blood tests are important but not as urgent as identifying EPS. Choice C is irrelevant as tyramine interactions are not associated with risperidone. Choice D is incorrect as weight gain is more common than weight loss with risperidone.

4. A client with bipolar disorder, manic phase, is admitted to the psychiatric unit. Which meal is most appropriate for this client?

• A. Spaghetti and meatballs
• B. Chicken salad sandwich
• C. Steak and potatoes
• D. Hamburger and fries

Correct answer: B

Rationale: A chicken salad sandwich (B) is the most appropriate choice as it is easy to eat on the go, which is important for a client in the manic phase who may have difficulty sitting still for a meal. Spaghetti and meatballs (A) and steak and potatoes (C) require more time and effort to eat, which may be challenging for a client experiencing mania. While hamburger and fries (D) could be an option, a chicken salad sandwich is a healthier and more manageable choice, considering the client's potential hyperactive state.

5. The LPN/LVN is caring for a client who has been prescribed a monoamine oxidase inhibitor (MAOI) for depression. Which statement by the client indicates a need for further teaching?

• A. I need to avoid foods that are high in tyramine, like aged cheese and cured meats.
• B. I should take this medication with food to avoid nausea.
• C. I can drink alcohol in moderation while taking this medication.
• D. I can stop taking this medication once I feel better.

Correct answer: C

Rationale: The statement 'I can drink alcohol in moderation while taking this medication' indicates a need for further teaching because alcohol consumption can have dangerous interactions with MAOIs. MAOIs can interact with alcohol to cause a hypertensive crisis, which can be life-threatening. Choices A and B are correct statements as avoiding tyramine-rich foods and taking the medication with food can help prevent adverse effects. Choice D is incorrect because abruptly stopping an antidepressant medication like an MAOI can lead to withdrawal symptoms and a relapse of depression.

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