Nursing Elites

1. An elderly client was prescribed Ativan 1 mg three times a day to help calm her anxiety after her husband's death. The next day the client calls her daughter asking when she is picking her up to go to the graveside. The client says she has been walking up and down the driveway for the past hour waiting for her daughter. Noting the client's agitation, hyperactivity, and insistence, the daughter calls the nurse to report her mother's behavior. What should the nurse suspect?

• A. The client is manic and may need a sleeping pill
• B. The client is experiencing a medication interaction and should go to the ED
• C. The client is experiencing a paradoxical reaction to the Ativan and should stop the new medication immediately
• D. The client is overcome by grief and probably needs an antidepressant

Correct answer: C

Rationale: A paradoxical reaction to Ativan, where the drug causes opposite effects such as increased agitation and hyperactivity, should prompt immediate cessation of the medication. In this scenario, the client was prescribed Ativan to help calm her anxiety, but instead, she is displaying symptoms of increased agitation and hyperactivity, indicating a paradoxical reaction. Choice A is incorrect because the symptoms described do not align with mania. Choice B is incorrect as there is no mention of a medication interaction. Choice D is incorrect as the symptoms are more indicative of a paradoxical reaction rather than overwhelming grief.

2. A client is admitted to the psychiatric unit with a diagnosis of major depressive disorder. The LPN/LVN notes that the client has not bathed or dressed in clean clothes for several days. What is the most appropriate intervention for the nurse to implement?

• A. Encourage the client to take a shower.
• B. Assist the client with activities of daily living.
• C. Provide the client with clean clothes to change into.
• D. Explain the importance of personal hygiene to the client.

Correct answer: B

Rationale: The correct answer is to assist the client with activities of daily living. This intervention is the most appropriate as it directly addresses the client's immediate needs by providing assistance with personal hygiene and dressing. It promotes self-care and ensures the client's well-being. Encouraging the client to take a shower (Choice A) may not be effective if the client is unable to do so independently due to their condition. Providing clean clothes (Choice C) is important but does not address the client's need for assistance with personal care. Explaining the importance of personal hygiene (Choice D) may not be as effective as providing direct assistance in this situation.

3. A 52-year-old male client in the intensive care unit who has been oriented suddenly becomes disoriented and fearful. Assessment of vital signs and other physical parameters reveal no significant change, and the nurse formulates the diagnosis, 'Confusion related to ICU psychosis.' Which intervention would be best to implement?

• A. Move all machines away from the client's immediate area.
• B. Attempt to allay the client's fears by explaining the etiology of his condition.
• C. Cluster care so that brief periods of rest can be scheduled during the day.
• D. Extend visitation times for family and friends.

Correct answer: C

Rationale: In critical care environments, stressors can lead to isolation and confusion. Providing the client with scheduled rest periods (C) can help alleviate these symptoms. Moving all machines away (A) is impractical as they are often essential. Explaining the condition (B) may not be effective during acute confusion. Extending visitation times (D) can be overwhelming for the client in the ICU.

4. A client diagnosed with bipolar disorder tells the nurse that she wants to stop taking her lithium. She states, 'I feel fine, and I don't think I need it anymore.' What should the nurse do first?

• A. Agree with the client that she seems fine now.
• B. Remind the client of the importance of lithium.
• C. Ask the healthcare provider to discontinue the lithium prescription.
• D. Arrange for a psychiatric evaluation for the client.

Correct answer: B

Rationale: When a client with bipolar disorder expresses a desire to stop taking lithium because they feel fine, the nurse's initial action should be to remind the client of the importance of lithium. This approach helps educate the client about the necessity of medication adherence in managing bipolar disorder. Agreeing with the client or immediately arranging a psychiatric evaluation may not address the root issue of medication non-adherence. Asking the healthcare provider to discontinue the prescription without further assessment and intervention could potentially jeopardize the client's stability and treatment plan.

5. A client in the manic phase of bipolar disorder is pacing the hallway and talking rapidly. What is the best intervention for the nurse?

• A. Encourage the client to join a group activity.
• B. Offer the client a high-calorie snack and a drink.
• C. Direct the client to a quieter area of the unit.
• D. Instruct the client to sit down and relax.

Correct answer: B

Rationale: In the manic phase of bipolar disorder, clients often exhibit increased activity and may burn a lot of energy. Offering a high-calorie snack and a drink is the best intervention as it helps maintain their nutritional needs while allowing them to continue their activity. Encouraging the client to join a group activity (Choice A) may further stimulate their behavior. Directing the client to a quieter area (Choice C) might not address their energy expenditure. Instructing the client to sit down and relax (Choice D) may not be effective during the manic phase.

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