Nursing Elites

1. A teenaged client, a heroin addict, is admitted to the unit for detoxification. What intervention is most important for the nurse to initiate during the first 24 hours after admission?

• A. Assign the client to a teen support group.
• B. Assess intake and output.
• C. Monitor for wheezing and apnea.
• D. Limit visitors to family members only.

Correct answer: B

Rationale: Assessing intake and output is crucial during the first 24 hours after admission for detoxification. This helps the nurse monitor the client's hydration status and kidney function as the body goes through withdrawal from heroin. Option A is incorrect because joining a support group is beneficial but may not be the priority in the initial phase of detoxification. Option C, monitoring for wheezing and apnea, is important but not the most critical intervention during the first 24 hours. Option D, limiting visitors to family members only, is not directly related to the immediate needs of assessing intake and output.

2. A 35-year-old male client on the psychiatric unit of a general hospital believes that someone is trying to poison him. The nurse understands that a client's delusions are most likely related to his

• A. early childhood experiences involving authority issues.
• B. anger about being hospitalized.
• C. low self-esteem.
• D. phobic fear of food.

Correct answer: C

Rationale: Psychotic clients often experience delusions due to difficulties with trust and low self-esteem (C). In this case, the client's belief that someone is trying to poison him is likely a manifestation of his underlying issues with trust and self-worth. Building trust and promoting positive self-esteem are essential in caring for such clients. Choices A, B, and D are incorrect because delusions are not primarily related to early childhood experiences involving authority issues, anger about hospitalization, or phobic fear of food. These factors do not directly contribute to the development of delusions in psychotic clients.

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 male client who is participating in an anger management assignment asks if he can make a leather belt in occupational therapy. The client begins pounding the leather vigorously with a mallet to imprint designs on the belt. What defense mechanism is the client using?

• A. Sublimation
• B. Suppression
• C. Regression
• D. Compensation

Correct answer: A

Rationale: The correct answer is A, Sublimation. Sublimation is a defense mechanism where unacceptable impulses are redirected into socially acceptable activities, such as art or work. In this scenario, the client is channeling his anger into a creative and constructive task like making a leather belt. Choice B, Suppression, involves consciously pushing down or hiding feelings rather than expressing them through alternate means. Choice C, Regression, refers to reverting to earlier, immature behaviors when faced with stress. Choice D, Compensation, involves making up for a perceived weakness in one area by excelling in another, which is not demonstrated in the scenario provided.

5. A client with bipolar disorder is prescribed lithium. What is the most important instruction the nurse should provide?

• A. Avoid foods high in potassium while taking this medication.
• B. Take your medication with food to prevent nausea.
• C. Be sure to maintain a consistent sodium intake.
• D. You can stop taking the medication once your symptoms improve.

Correct answer: C

Rationale: Maintaining a consistent sodium intake is crucial for clients taking lithium because changes in sodium levels can impact lithium concentrations, potentially leading to toxicity. It is essential to avoid excessive sodium intake, as both low and high levels can affect lithium levels. Choices A, B, and D are incorrect. A high potassium diet is not a concern with lithium therapy. While taking lithium with food can help reduce gastrointestinal side effects, it is not the most important instruction. Finally, abruptly stopping lithium can lead to a recurrence of symptoms or a worsening of the condition, so it is vital to follow the prescribed regimen.

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