Nursing Elites

1. When planning care for a client with anorexia nervosa, which goal should be prioritized?

• A. The client will establish normal eating patterns.
• B. The client will verbalize feelings about food and weight.
• C. The client will gain a minimum of 2 pounds per week.
• D. The client will achieve normal electrolyte balance.

Correct answer: D

Rationale: The correct answer is D because achieving normal electrolyte balance is critical in clients with anorexia nervosa. Electrolyte imbalances can lead to serious, life-threatening complications such as cardiac arrhythmias and organ failure. While establishing normal eating patterns (choice A) and verbalizing feelings about food and weight (choice B) are important aspects of treatment, addressing electrolyte balance takes precedence due to the immediate risks associated with imbalances. Additionally, setting a weight gain goal of 2 pounds per week (choice C) may not be appropriate initially as rapid refeeding can also lead to electrolyte imbalances and other complications.

2. A client with bipolar disorder is being discharged with a prescription for lithium. What is the most important instruction the nurse should provide?

• A. Avoid foods high in sodium.
• B. Drink plenty of fluids, especially during hot weather.
• C. Take your medication with food.
• D. Monitor your blood pressure regularly.

Correct answer: B

Rationale: The correct answer is to instruct the client to drink plenty of fluids, especially during hot weather. Maintaining adequate hydration is crucial for clients taking lithium as dehydration can lead to lithium toxicity. Choice A is incorrect because while it is important to monitor sodium intake, staying hydrated is more critical. Choice C is incorrect as lithium is usually recommended to be taken with food to reduce stomach upset. Choice D is also important but not the most crucial instruction compared to ensuring proper hydration.

3. Select the nursing interventions for a hospitalized client with mania who is exhibiting manipulative behavior. Select one intervention that does not apply.

• A. Communicate expected behaviors to the client
• B. Ensure that the client knows that he or she is not in charge of the nursing unit
• C. Assist the client in identifying ways of setting limits on personal behaviors
• D. Follow through about the consequences of behavior in a non-punitive manner

Correct answer: B

Rationale: The correct answer is B. Ensuring that the client knows they are not in charge of the nursing unit is not a helpful nursing intervention for managing manipulative behavior in a client with mania. Communicating expected behaviors, assisting with limit-setting, and following through on consequences in a non-punitive manner are more appropriate interventions to address manipulative behavior.

4. A client with a diagnosis of schizophrenia is prescribed risperidone (Risperdal). Which statement by the client indicates a need for further teaching?

• A. I can stop taking this medication once I feel better.
• B. I need to avoid foods that are high in tyramine.
• C. I should avoid drinking alcohol while taking this medication.
• D. This medication may cause drowsiness, so avoid driving.

Correct answer: A

Rationale: The correct answer is A. The statement 'I can stop taking this medication once I feel better' indicates a need for further teaching. Antipsychotic medications, like risperidone, should be taken consistently even when symptoms improve to prevent relapse. Choice B is incorrect because avoiding foods high in tyramine is unrelated to risperidone. Choice C is incorrect as avoiding alcohol is a standard precaution with many medications. Choice D is incorrect because being cautious about drowsiness and avoiding driving is a common safety measure associated with risperidone.

5. An 86-year-old female client with Alzheimer's disease is wandering the busy halls of the extended care facility and asks the nurse, 'Where should I stand for the parade?' Which response is best for the nurse to provide?

• A. "You can stand wherever you'd like as long as you stay safe from those in the parade."
• B. "You seem confused because of all the activity in the hall. There is no parade."
• C. "Let's go back to the activity room and see what is going on in there."
• D. "Remember, this is a nursing home, and I am here to help you."

Correct answer: C

Rationale: (C) is the best response as it redirects the client to a safer, familiar place. (A) is dismissive and does not address the client's needs directly. (B) labels the behavior, which may increase the client's anxiety. (D) is scolding and may not be helpful in the situation.

Similar Questions