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 client with panic disorder is experiencing a panic attack. What is the nurse's priority intervention?

• A. Encourage the client to breathe slowly and deeply.
• B. Ask the client to describe the sensations they are experiencing.
• C. Encourage the client to focus on a calming image.
• D. Administer a PRN dose of lorazepam (Ativan).

Correct answer: A

Rationale: The correct answer is A. Encouraging slow, deep breathing is the priority intervention during a panic attack as it can help reduce the physiological symptoms and assist the client in regaining control. This technique can help decrease hyperventilation and promote relaxation. Choice B, asking the client to describe sensations, may be beneficial after the panic attack has subsided to gain insight into triggers or manifestations. Choice C, encouraging the client to focus on a calming image, can be helpful in managing anxiety but may not be as effective during the acute phase of a panic attack. Choice D, administering a PRN dose of lorazepam (Ativan), should only be considered if the client does not respond to initial non-pharmacological interventions or if the symptoms are severe and unmanageable.

3. A male client turns over a table in the dayroom of a psychiatric unit and threatens to throw a chair at another client. Which action is most important for the nurse to implement?

• A. Calmly approach the client and remove the chair from the client.
• B. Obtain staff assistance to help diffuse the escalating situation.
• C. Offer feedback about the client's behavior.
• D. Summon the hospital security guards as a 'show of force.'

Correct answer: B

Rationale: In a situation where a client is displaying aggressive behavior, the most important action for the nurse to implement is to obtain staff assistance to help diffuse the escalating situation. This approach ensures the safety of all individuals involved and prevents the situation from escalating further. Calmly approaching the client and removing the chair directly could agitate the client further and pose a risk to the nurse. Offering feedback about the client's behavior may not address the immediate safety concerns. Summoning hospital security guards as a 'show of force' should be a last resort after other de-escalation attempts have failed, as it may further provoke the client.

4. When caring for a client who has overdosed on PCP, the nurse should be especially cautious about which of the following client behaviors?

• A. Visual hallucinations
• B. Violent behavior
• C. Bizarre behavior
• D. Loud screaming

Correct answer: B

Rationale: The correct answer is B: 'Violent behavior.' When a client has overdosed on PCP, the nurse should be particularly cautious about the manifestation of violent behavior. PCP overdose can lead to aggressive and unpredictable actions, posing a significant risk to both the client and healthcare providers. Visual hallucinations (choice A), bizarre behavior (choice C), and loud screaming (choice D) can also occur with PCP overdose, but the primary concern should be the potential for violent behavior, making it the most critical behavior to monitor and manage.

5. An adolescent with major depressive disorder has been taking duloxetine (Cymbalta) for the past 12 days. Which assessment finding requires immediate follow-up?

• A. Describes life as without purpose.
• B. Exhibits an increase in sweating.
• C. States is often fatigued and drowsy.
• D. Complains of nausea and loss of appetite.

Correct answer: A

Rationale: The correct answer is A. Expressing that life is without purpose can indicate deepening depression or suicidal ideation, which requires immediate attention. While sweating, fatigue, drowsiness, nausea, and loss of appetite can be side effects of duloxetine (Cymbalta), they do not indicate the same level of urgency as a statement suggesting deepening depression or suicidal ideation.

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