Nursing Elites

1. While working with a male client at a community mental health center, the client reports hearing voices that tell him to get a knife from the kitchen and hurt himself. What intervention is most important for the RN to implement?

• A. Prevent the client from going into the kitchen until the hallucination subsides.
• B. Report the behavior to the client’s case worker to inform the family.
• C. Assign a UAP to stay with the client continually.
• D. Document the behavior in the client’s record and notify the HCP.

Correct answer: A

Rationale: The most crucial intervention for the RN to implement in this scenario is to prevent the client from accessing the kitchen where potential means of self-harm are available until the hallucination subsides. This immediate action is necessary to ensure the client's safety. While reporting the behavior to the client's case worker for further support is important, addressing the immediate risk of harm takes precedence. Assigning a UAP to stay with the client continually is valuable for ongoing monitoring but is secondary to ensuring immediate safety. Documenting the behavior in the client's record and notifying the healthcare provider are essential steps in the care process; however, they should follow actions taken to ensure the client's immediate safety.

2. The RN documents the mental status of a female client who has been hospitalized for several days by court order. The client states, “I don’t need to be here,” and tells the RN that she believes that the TV talks to her. The RN should document these assessment statements in which section of the mental status exam?

• A. Insight and judgment.
• B. Mood and affect.
• C. Remote memory.
• D. Level of concentration.

Correct answer: A

Rationale: The client's statement of not needing to be hospitalized and her belief that the TV talks to her indicate impaired insight and judgment. Insight and judgment evaluate the client's awareness of their condition and ability to make sound decisions. Mood and affect assess emotional state, remote memory evaluates recall of past events, and level of concentration assesses attention and focus. In this scenario, the client's lack of awareness of her need for hospitalization and presence of delusions about the TV speaking to her directly relate to insight and judgment, making choice A the correct option.

3. A male client with schizophrenia is being discharged from the psychiatric unit after being stabilized with antipsychotic medications. What is the most important instruction to include in the discharge teaching?

• A. “You should see your psychiatrist every 6 months.”
• B. “It’s important to adhere to the medication regimen as prescribed.”
• C. “Try to avoid caffeine and alcohol completely.”
• D. “You should exercise daily to maintain a healthy lifestyle.”

Correct answer: B

Rationale: The most important instruction to include in the discharge teaching for a male client with schizophrenia who has been stabilized with antipsychotic medications is to adhere to the medication regimen as prescribed. Medication adherence is crucial in managing schizophrenia, preventing relapse, and maintaining stability. While seeing the psychiatrist regularly (Choice A) is important, adherence to medication is more critical for the client's immediate well-being. Avoiding caffeine and alcohol (Choice C) may be beneficial but is not as crucial as medication adherence. Daily exercise (Choice D) is important for overall health but is not the most critical instruction for managing schizophrenia.

4. A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of risperidone (Risperdal). When the client walks to the nurse’s station in a laterally contracted position, he states that something has made his body contort into a monster. What action should the nurse take?

• A. Medicate the client with the prescribed antipsychotic thioridazine (Mellaril).
• B. Offer the client a prescribed physical therapy hot pack for muscle spasms.
• C. Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia.
• D. Direct the client to occupational therapy to distract him from somatic complaints.

Correct answer: C

Rationale: The client is experiencing a dystonic reaction due to dopamine depletion, which is a known side effect of Risperidone. Dystonia presents as abnormal muscle contractions and postures. The immediate management for this side effect is the administration of an anticholinergic medication like Benztropine (Cogentin). Choice A is incorrect as thioridazine is not the recommended medication for dystonic reactions. Choice B is incorrect as a hot pack would not effectively address the underlying cause of the dystonic reaction. Choice D is incorrect as occupational therapy is not the appropriate intervention for managing acute dystonia.

5. 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.

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