Nursing Elites

1. The LPN/LVN is assessing a client who is taking an antipsychotic medication. Which of the following symptoms is uniquely indicative of neuroleptic malignant syndrome (NMS) and requires immediate attention?

• A. Very high temperature
• B. Muscular rigidity
• C. Tremors
• D. Altered consciousness

Correct answer: A

Rationale: A very high temperature is a hallmark symptom of Neuroleptic Malignant Syndrome (NMS), which is a rare but potentially life-threatening side effect of antipsychotic medications. This symptom is uniquely indicative of NMS and requires immediate medical attention. Muscular rigidity, tremors, and altered consciousness can be seen in other conditions but are not as specifically linked to NMS as a very high temperature.

2. 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.

3. An older homeless client visits the psychiatric clinic to obtain a prescription renewal for alprazolam (Xanax). During the health assessment, the client complains of chest pain. Which action should the RN take first?

• A. Refer the client to the cardiology unit.
• B. Obtain the client's blood pressure.
• C. Assess the client for substance abuse.
• D. Determine if Xanax was taken recently.

Correct answer: D

Rationale: Determining if Xanax was taken recently is crucial as it helps assess whether the chest pain is related to medication use or another issue, guiding appropriate immediate care. This action can provide essential information to address the client's current complaint effectively. Referring the client to the cardiology unit (Choice A) may be premature without assessing the Xanax use first. While obtaining the client's blood pressure (Choice B) is important, it is not the priority when the client presents with chest pain and a history of taking Xanax. Assessing the client for substance abuse (Choice C) is also important but is secondary to first determining the potential link between Xanax and the chest pain.

4. The nurse is planning the care for a 32-year-old male client with acute depression. Which nursing intervention would be best in helping this client deal with his depression?

• A. Ensure that the client's day is filled with group activities.
• B. Assist the client in exploring feelings of shame, anger, and guilt.
• C. Allow the client to initiate and determine activities of daily living.
• D. Encourage the client to explore the rationale for his depression.

Correct answer: B

Rationale: Assisting the client in exploring feelings of shame, anger, and guilt (B) is the most appropriate intervention for acute depression as it helps address core emotions that may be contributing to the condition. Focusing on these emotions can aid the client in processing and coping with their feelings. Ensuring that the client's day is filled with group activities (A) might overwhelm the client, as they may not be ready for social interactions during this sensitive time. Allowing the client to initiate and determine activities of daily living (C) is more suitable for chronic cases where the client needs to regain autonomy. Encouraging the client to explore the rationale for his depression (D) is less effective in acute cases, as the focus should be on immediate emotional support and understanding rather than cognitive analysis.

5. A client with generalized anxiety disorder (GAD) is prescribed buspirone (BuSpar). The client asks how long it will take for the medication to start working. What is the nurse's best response?

• A. You should start feeling better within a few days.
• B. It may take 2 to 4 weeks before you notice an improvement.
• C. Buspirone works immediately to reduce anxiety symptoms.
• D. You will need to take this medication for at least a year.

Correct answer: B

Rationale: The correct answer is B. Buspirone typically takes 2 to 4 weeks to become fully effective. It is essential to inform the client that it may take some time before they notice an improvement. Choice A is incorrect because buspirone does not work immediately. Choice C is also incorrect as buspirone does not provide immediate relief. Choice D is incorrect as it suggests a longer duration of treatment than necessary.

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