Nursing Elites

1. A patient with schizophrenia is experiencing hallucinations. Which intervention is most appropriate?

• A. Encourage the patient to ignore the voices.
• B. Engage the patient in a reality-based activity.
• C. Provide a quiet environment to reduce stimulation.
• D. Ask the patient to describe the hallucinations in detail.

Correct answer: B

Rationale: Engaging the patient in a reality-based activity is the most appropriate intervention for a patient with schizophrenia experiencing hallucinations. This intervention can help distract the patient from the hallucinations and reorient them to the present, promoting a connection with reality and potentially reducing distress associated with the hallucinations. Choice A, encouraging the patient to ignore the voices, may not be effective as it can be challenging for the patient to dismiss the hallucinations. Choice C, providing a quiet environment, is helpful but may not directly address the hallucinations. Choice D, asking the patient to describe the hallucinations in detail, may increase the patient's focus on the hallucinations, potentially worsening distress.

2. A client with bipolar disorder is prescribed lithium. Which dietary instruction should the nurse provide?

• A. Avoid foods high in potassium.
• B. Increase intake of caffeinated beverages.
• C. Maintain consistent sodium intake.
• D. Follow a low-protein diet.

Correct answer: C

Rationale: The correct instruction for a client with bipolar disorder prescribed lithium is to maintain consistent sodium intake. Fluctuations in sodium levels can impact lithium levels, potentially leading to toxicity. Therefore, it is crucial to advise the client to keep their sodium intake consistent to ensure the effectiveness and safety of the lithium therapy. Choices A, B, and D are incorrect. Avoiding foods high in potassium is not directly related to lithium therapy. Increasing intake of caffeinated beverages can interfere with the action of lithium. Following a low-protein diet is not a standard recommendation for clients prescribed lithium.

3. Maggie, a child in protective custody, is found to have an imaginary friend, Holly. Her foster family shares this information with the nurse. The nurse teaches the family members about children who have suffered trauma and knows her teaching was effective when the foster mother states:

• A. I understand that imaginary friends are abnormal.
• B. I understand that imaginary friends are a maladaptive behavior.
• C. I understand that imaginary friends are a coping mechanism.
• D. I understand that we should tell the child that imaginary friends are unacceptable.

Correct answer: C

Rationale: Imaginary friends can serve as a coping mechanism for children, especially those who have experienced trauma. They can provide comfort and a sense of control in challenging situations. Acknowledging and supporting the child's imaginary friend can be beneficial in their emotional healing and development.

4. A client with obsessive-compulsive disorder (OCD) is being cared for by a nurse. Which intervention should the nurse include in the plan of care?

• A. Encourage the client to suppress compulsive behaviors.
• B. Set strict limits on the amount of time the client can engage in compulsive behaviors.
• C. Allow the client to perform compulsive behaviors as needed.
• D. Gradually limit the amount of time allotted for compulsive behaviors.

Correct answer: D

Rationale: In caring for a client with OCD, it is essential to gradually limit the time allotted for compulsive behaviors. This intervention helps the client develop alternative coping mechanisms. Encouraging suppression or setting strict limits on compulsive behaviors can exacerbate the client's anxiety, making it crucial to approach the care plan with a gradual reduction strategy. Allowing the client to perform compulsive behaviors as needed does not promote progress towards managing OCD symptoms and may reinforce maladaptive patterns of behavior.

5. A patient with schizophrenia is prescribed clozapine. Which potential side effect requires regular monitoring?

• A. Weight loss
• B. Hypertension
• C. Agranulocytosis
• D. Hyperthyroidism

Correct answer: C

Rationale: When a patient with schizophrenia is prescribed clozapine, regular monitoring for agranulocytosis is essential. Agranulocytosis is a severe reduction in white blood cells that can be life-threatening. Monitoring white blood cell counts is crucial to detect this side effect early and prevent serious complications. Weight loss (Choice A) is not a common side effect of clozapine. Hypertension (Choice B) and hyperthyroidism (Choice D) are also not typically associated with clozapine use, making them incorrect choices for regular monitoring.

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