Nursing Elites

1. An adult male client who was admitted to the mental health unit yesterday tells the nurse that microchips were planted in his head for military surveillance of his every move. Which response is best for the nurse to provide?

• A. You are in the hospital, and I am the nurse caring for you
• B. It must be difficult for you to control your anxious feelings
• C. Go to occupational therapy and start a project
• D. You are not in a war area now; this is the United States

Correct answer: C

Rationale: Delusions often generate fear and isolation, so the nurse should help the client participate in activities that avoid focusing on the false belief and encourage interaction with others.

2. A young adult male with a history of substance abuse is admitted to the psychiatric unit for detoxification. He is agitated, sweating, and reports seeing bugs crawling on the walls. What is the priority nursing intervention?

• A. Reassure the client that the bugs are not real.
• B. Administer the prescribed benzodiazepine.
• C. Place the client in a quiet, dark room.
• D. Encourage the client to express his feelings.

Correct answer: B

Rationale: The correct answer is to administer the prescribed benzodiazepine. This intervention helps manage the client's agitation and hallucinations, which are common symptoms during detoxification from substances. Reassuring the client that the bugs are not real (Choice A) may not be effective in addressing the underlying causes of the hallucinations. Placing the client in a quiet, dark room (Choice C) may help reduce sensory stimulation but does not directly address the client's symptoms. Encouraging the client to express his feelings (Choice D) is important for therapeutic communication but may not be the priority when the client is experiencing severe agitation and hallucinations.

3. A client with generalized anxiety disorder is being taught about buspirone (BuSpar) by a nurse. Which statement by the client indicates a need for further teaching?

• A. I should take this medication on an empty stomach.
• B. It may take several weeks before I feel better.
• C. This medication does not cause dependence.
• D. I can drink alcohol while taking this medication.

Correct answer: D

Rationale: The statement 'I can drink alcohol while taking this medication' (D) indicates a need for further teaching. Clients should avoid alcohol while taking buspirone because it can increase the risk of side effects such as dizziness and drowsiness. Choices A, B, and C are correct statements regarding buspirone and do not require further teaching.

4. A nurse is caring for a client with depression who has been prescribed sertraline (Zoloft). The client reports experiencing nausea. What is the nurse's best response?

• A. "You should stop taking the medication immediately."
• B. "Nausea is a common side effect and usually decreases over time."
• C. "Try taking the medication with food to reduce nausea."
• D. "I will inform the healthcare provider to change your medication."

Correct answer: B

Rationale: The correct answer is B: "Nausea is a common side effect of sertraline, and clients should be reassured that it usually decreases as their body adjusts to the medication." Choice A is incorrect because abruptly stopping the medication without consulting a healthcare provider can be harmful. Choice C is a good suggestion to reduce nausea by taking the medication with food but does not address the temporary nature of the side effect. Choice D is unnecessary at this point since nausea is a common side effect that may improve with time.

5. During a manic episode, what is the most appropriate nursing intervention for a client with bipolar disorder?

• A. Allow the client to engage in any activities they choose.
• B. Provide a quiet and structured environment.
• C. Encourage the client to participate in group activities.
• D. Allow the client to take short naps during the day.

Correct answer: B

Rationale: During a manic episode, individuals with bipolar disorder often experience excessive energy and impulsivity. Providing a quiet and structured environment is crucial to help manage these symptoms. This intervention promotes stability, reduces overstimulation, and supports the client in regaining control over their behaviors. Choices A and C may exacerbate impulsivity and overstimulation, while choice D does not address the need for environmental structure and may not be effective in managing manic symptoms.

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