Nursing Elites

1. The healthcare professional is developing a discharge plan for a client recovering from alcohol withdrawal. Which instruction should be included in the client’s discharge teaching?

• A. Avoid all social situations involving alcohol.
• B. Continue taking prescribed medications.
• C. Contact a support group such as Alcoholics Anonymous.
• D. Avoid using any over-the-counter medications.

Correct answer: C

Rationale: It is essential to include instructions for the client to contact a support group like Alcoholics Anonymous in their discharge teaching. Support groups play a vital role in providing ongoing support, guidance, and encouragement during the recovery process from alcohol withdrawal, helping to prevent relapse. Choice A is incorrect because avoiding all social situations involving alcohol may not be practical or sustainable in the long term. Choice B is important but is not specific to the client's alcohol recovery needs. Choice D is not the top priority compared to the importance of connecting with a support group for ongoing assistance and accountability.

2. A male client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. What intervention is best for the nurse to implement?

• A. Avoid acknowledging the behavior.
• B. Isolate the client from other clients.
• C. Administer a PRN sedative.
• D. Escort the client to his room.

Correct answer: D

Rationale: The best intervention for a male client with schizophrenia displaying echolalia, which is disruptive to others, is for the nurse to escort the client to his room. Echolalia, the constant repetition of others' words, can be disruptive in a communal setting. By guiding the client to a private space like his room, the nurse helps manage the behavior without isolating or medicating the client unnecessarily. Avoiding acknowledging the behavior (Choice A) does not address the issue, isolating the client (Choice B) may exacerbate feelings of exclusion, and administering a PRN sedative (Choice C) should be reserved for situations where there is imminent risk or severe agitation, not for managing echolalia.

3. A client with a history of bipolar disorder is exhibiting symptoms of mania. Which intervention is most appropriate for the nurse to implement?

• A. Encourage the client to participate in group therapy.
• B. Provide a calm and structured environment.
• C. Limit stimulation and set firm limits on behavior.
• D. Promote self-care and hygiene practices.

Correct answer: C

Rationale: When a client with bipolar disorder is experiencing symptoms of mania, the most appropriate intervention for the nurse is to limit stimulation and set firm limits on behavior. This approach helps in managing the manic episode by preventing further escalation. Encouraging participation in group therapy (Choice A) may not be effective during the acute phase of mania, as the client may have difficulty focusing or following group discussions. Providing a calm and structured environment (Choice B) is beneficial, but setting firm limits is crucial to managing the impulsivity and risky behaviors associated with mania. Promoting self-care practices (Choice D) is important, but during a manic episode, setting limits and reducing stimuli take precedence over hygiene practices.

4. A female client on a psychiatric unit is sweating profusely while vigorously doing push-ups and then running the length of the corridor several times before crashing into furniture in the sitting room. Picking herself up, she begins to toss chairs aside, looking for a red one to sit in. When another client objects to the disturbance, the client shouts, “I am the boss here. I do what I want.” Which nursing problem best supports these observations?

• A. Deficient diversional activity related to excess energy level.
• B. Disturbed personal identity related to grandiosity.
• C. Risk for activity intolerance related to hyperactivity.
• D. Risk for other-directed violence related to disruptive behaviors.

Correct answer: D

Rationale: The client's behavior of engaging in disruptive and aggressive actions, as well as claiming authority over others in the setting, indicates a risk for other-directed violence. This behavior poses a potential threat to the safety of others in the environment. Choice A is incorrect as the client's behavior is not solely indicative of a lack of diversional activities but rather a more serious issue. Choice B is incorrect as the behavior described does not primarily reflect disturbances in personal identity but rather displays of power and aggression. Choice C is incorrect as the client's actions do not suggest an intolerance to activity but rather an excessive and potentially harmful level of hyperactivity.

5. A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The nurse also determines that the client is homeless and slightly suspicious. This client’s treatment plan should include what priority problem?

• A. Self-care deficit.
• B. Disturbed sensory perception.
• C. Ineffective community coping.
• D. Acute confusion.

Correct answer: D

Rationale: The correct answer is 'D: Acute confusion.' In the given scenario, the client is disoriented, disorganized, and confused, indicating acute confusion. This is a priority issue to address for immediate safety and appropriate care. Option A, self-care deficit, is not the priority as the client's safety and mental status take precedence over self-care. Option B, disturbed sensory perception, is not applicable as the client's symptoms focus more on cognitive rather than sensory issues. Option C, ineffective community coping, is not the immediate concern as the client's cognitive state needs urgent attention to ensure her safety and well-being.

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