Nursing Elites

1. Which medication would the nurse least likely use to provide immediate intervention for an angry psychotic client?

• A. Lithium
• B. Alprazolam
• C. Diphenhydramine
• D. Haloperidol

Correct answer: B

Rationale: Alprazolam is a benzodiazepine commonly used for anxiety disorders. While it may help calm an individual, it is not typically the first-line choice for managing acute agitation in a psychotic client. Haloperidol, on the other hand, is a typical antipsychotic medication often used for immediate intervention in psychiatric emergencies involving aggression or psychosis.

2. A client diagnosed with borderline personality disorder has been admitted to the psychiatric unit after a suicide attempt. Which of the following actions should the nurse take first?

• A. Encourage the client to express feelings about the suicide attempt.
• B. Place the client on one-to-one observation.
• C. Discuss the client's feelings about the suicide attempt.
• D. Encourage the client to participate in group therapy.

Correct answer: B

Rationale: The initial priority for the nurse is to ensure the safety of the client. Placing the client on one-to-one observation allows for constant monitoring and intervention if there are any signs of self-harm or a worsening condition. This immediate intervention is crucial to prevent further harm. Options A, C, and D involve therapeutic communication and interventions, which are important but should come after ensuring the client's safety.

3. A client with post-traumatic stress disorder (PTSD) is experiencing flashbacks. Which of the following interventions should the nurse implement?

• A. Encourage the client to ignore the flashbacks.
• B. Stay with the client and offer reassurance.
• C. Instruct the client to avoid discussing the traumatic event.
• D. Encourage the client to engage in group therapy.

Correct answer: B

Rationale: During a flashback, it is essential for the nurse to stay with the client and offer reassurance. This approach can help the client feel safe and supported during a distressing experience. Encouraging the client to ignore the flashbacks may lead to increased anxiety and distress. Instructing the client to avoid discussing the traumatic event can hinder the therapeutic process of addressing and processing the trauma. While group therapy can be beneficial, it may not be the immediate intervention needed during a flashback.

4. When interviewing a distressed client who was fired after 15 years of loyal employment, which of the following questions would best assist in determining the client's appraisal of the situation? Select all that apply.

• A. What caused the stressful situation?
• B. Have you ever experienced a similar stressful situation?
• C. Who do you think is to blame for this situation?
• D. Why do you think you were fired from your job?

Correct answer: B

Rationale: The question 'Have you ever experienced a similar stressful situation?' is the most appropriate as it assesses the client's coping resources and encourages reflection on past experiences. This question can help the client consider alternative ways to deal with stress. Asking about the cause of the stressful situation may provide insight into the current situation but does not directly assess coping abilities. Inquiring about blame does not focus on coping strategies but may encourage negative thinking and a sense of victimization. Questioning why the client was fired is a nontherapeutic approach that can hinder communication by putting the client on the defensive.

5. A patient with schizophrenia is prescribed olanzapine. The nurse should monitor the patient for which common side effect?

• A. Weight gain
• B. Hypotension
• C. Hair loss
• D. Hyperthyroidism

Correct answer: A

Rationale: Weight gain is a common side effect of olanzapine, an atypical antipsychotic. Olanzapine is known to cause metabolic changes that can lead to weight gain. Monitoring weight regularly is essential to detect and manage this side effect to prevent associated health risks such as diabetes and cardiovascular issues. Hypotension (choice B) is not a common side effect of olanzapine. Olanzapine is more likely to cause orthostatic hypotension, which is a sudden drop in blood pressure when changing positions. Hair loss (choice C) and hyperthyroidism (choice D) are not typically associated with olanzapine use.

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