Nursing Elites

1. The nurse is preparing to administer phenelzine sulfate (Nardil) to a client on the psychiatric unit. Which complaint related to administration of this drug should the nurse expect this client to make?

• A. My mouth feels like cotton.
• B. That medication gives me indigestion.
• C. This pill gives me diarrhea.
• D. My urine looks pink.

Correct answer: A

Rationale: Dry mouth is a common side effect of MAO inhibitors like phenelzine due to their anticholinergic effects. Choices B, C, and D are incorrect as indigestion, diarrhea, and pink urine are not commonly associated side effects of phenelzine.

2. When caring for a client with borderline personality disorder in a psychiatric unit, what is the most therapeutic nursing intervention?

• A. Set clear and consistent boundaries for the client.
• B. Allow the client to vent their feelings without interruption.
• C. Encourage the client to participate in group therapy.
• D. Provide the client with frequent reassurance and support.

Correct answer: A

Rationale: Setting clear and consistent boundaries is the most therapeutic nursing intervention when caring for a client with borderline personality disorder. This approach provides structure, promotes predictability, and helps prevent manipulative behaviors. By establishing boundaries, the nurse can maintain a safe therapeutic relationship with the client. Allowing the client to vent their feelings without interruption (Choice B) may not always be beneficial, as it could reinforce maladaptive behaviors. Encouraging participation in group therapy (Choice C) can be helpful but setting boundaries is more critical for individualized care. Providing the client with frequent reassurance and support (Choice D) may not address the underlying issues and can contribute to dependency rather than fostering independence and coping skills.

3. When caring for a client with borderline personality disorder, what is the most effective nursing intervention?

• A. Set clear and consistent boundaries for the client.
• B. Allow the client to vent their feelings without interruption.
• C. Encourage the client to participate in group therapy.
• D. Provide the client with frequent reassurance and support.

Correct answer: A

Rationale: Setting clear and consistent boundaries is essential when caring for a client with borderline personality disorder. This intervention helps provide structure, maintain a therapeutic relationship, and prevent manipulative behaviors. Allowing the client to vent feelings without interruption (Choice B) may not address the underlying issues effectively. Encouraging participation in group therapy (Choice C) can be beneficial but setting boundaries is more crucial. Providing frequent reassurance and support (Choice D) may inadvertently reinforce maladaptive behaviors instead of promoting growth and independence.

4. A 65-year-old female client complains to the nurse that recently she has been hearing voices. What question should the nurse ask this client first?

• A. Do you have problems with hallucinations?
• B. Are you ever alone when you hear the voices?
• C. Has anyone in your family had hearing problems?
• D. Do you see things that others cannot see?

Correct answer: B

Rationale: The nurse should first ask if the client is ever alone when she hears the voices. This question helps differentiate between potential auditory hallucinations and other causes like hearing loss. Choice A is not the best first question as it assumes the client is experiencing hallucinations without exploring other possibilities. Choice C is irrelevant to the immediate concern of hearing voices. Choice D pertains to visual hallucinations which are not described in the client's complaint of hearing voices.

5. A male client with mental illness and substance dependency tells the mental health nurse that he has started using illegal drugs again and wants to seek treatment. Since he has a dual diagnosis, which person is best for the nurse to refer this client to first?

• A. The emergency room nurse.
• B. His case manager.
• C. The clinic healthcare provider.
• D. His support group sponsor.

Correct answer: B

Rationale: The case manager (B) is responsible for coordinating community services, making them the best person to refer the client to first as they can describe available treatment options. The emergency room nurse (A) is unnecessary unless the client's behaviors pose imminent threats. The clinic healthcare provider (C) and support group sponsor (D) may be useful but coordinating a treatment program tailored to the client's needs is the priority in this scenario.

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