Nursing Elites

1. 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.

2. A client with an eating disorder is planning to attend group meetings with Overeaters Anonymous. The LPN/LVN describes this group to the client, knowing that which finding(s) are characteristic of this form of self-help group? Select one that does not apply.

• A. A common goal is shared by all members
• B. Members are required to remain anonymous
• C. The leader is a professional mental health care provider
• D. Attendance must be prescribed by the health care provider

Correct answer: A

Rationale: Overeaters Anonymous is a self-help group characterized by shared goals among members to address eating disorders. This provides a supportive environment for personal change and growth. Choice B is incorrect as members are not required to remain anonymous in Overeaters Anonymous. Choice C is incorrect as the leader in such self-help groups is usually a member who has experienced similar issues, not necessarily a professional mental health care provider. Choice D is incorrect as attendance at Overeaters Anonymous meetings is voluntary and not prescribed by a healthcare provider.

3. The RN is preparing to administer a prescribed dose of haloperidol (Haldol) to a client with schizophrenia. The client begins to exhibit muscle rigidity, fever, and altered mental status. What action should the RN take first?

• A. Administer the haloperidol as prescribed.
• B. Monitor the client's vital signs closely.
• C. Hold the medication and notify the healthcare provider.
• D. Give the client an antipyretic for the fever.

Correct answer: C

Rationale: Muscle rigidity, fever, and altered mental status are symptoms of neuroleptic malignant syndrome (NMS), a potentially life-threatening reaction to antipsychotic medications. The RN should hold the medication and notify the healthcare provider immediately. Option A is incorrect because administering more of the medication can worsen the symptoms. Option B is not the first priority when the client is experiencing symptoms of NMS. Option D is incorrect as addressing the fever alone does not address the underlying issue of NMS caused by haloperidol.

4. A client diagnosed with undifferentiated schizophrenia is being discharged on aripiprazole (Abilify) 5 mg every night. When developing the teaching plan about the most common adverse effects, which of the following should the nurse include? Select one that does not apply.

• A. Headaches that will subside in a few weeks
• B. Transient mild anxiety
• C. Insomnia
• D. Torticollis

Correct answer: D

Rationale: The correct answer is D: Torticollis. Common side effects of aripiprazole include headaches, mild anxiety, and insomnia. These side effects are manageable during treatment. Torticollis is not a common adverse effect associated with aripiprazole and is more commonly seen with other medications or conditions. Therefore, the nurse should not include torticollis in the teaching plan about the most common adverse effects of aripiprazole.

5. A 38-year-old female client is admitted with a diagnosis of paranoid schizophrenia. When her tray is brought to her, she refuses to eat and tells the nurse, 'I know you are trying to poison me with that food.' Which response would be most appropriate for the nurse to make?

• A. 'I'll leave your tray here. I am available if you need anything else.'
• B. 'You're not being poisoned. Why do you think someone is trying to poison you?'
• C. 'No one on this unit has ever died from poisoning. You're safe here.'
• D. 'I will talk to your healthcare provider about the possibility of changing your diet.'

Correct answer: A

Rationale: Choice (A) offers support without confrontation, allowing the client to feel safe and respected. Choices (B) and (C) directly challenge the client's delusion, which can increase anxiety and distrust. Choice (D) focuses on a non-essential issue and does not address the client's immediate emotional needs.

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