Nursing Elites

1. A 22-year-old male client is admitted to the emergency center following a suicide attempt. His records reveal that this is his third suicide attempt in the past two years. He is conscious, but does not respond to verbal commands for treatment. Which assessment finding should prompt the nurse to prepare the client for gastric lavage?

• A. He ingested the drug 3 hours prior to admission to the emergency center.
• B. The family reports that he took an entire bottle of acetaminophen (Tylenol).
• C. He is unresponsive to instructions and is unable to cooperate with emetic therapy.
• D. Those with repeated suicide attempts desire punishment to relieve their guilt.

Correct answer: C

Rationale: The correct answer is C because the client's unresponsiveness to instructions and inability to cooperate with emetic therapy would make it challenging to implement such therapy effectively. In such cases, gastric lavage may be necessary to remove the ingested substance. Choices A and B are important considerations in treatment planning but do not directly indicate the need for gastric lavage. Choice D is incorrect as medical treatments should never be used as punitive measures but rather for therapeutic purposes.

2. An 86-year-old female client with Alzheimer's disease is wandering the busy halls of the extended care facility and asks the nurse, "Where should I stand for the parade?" Which response is best for the LPN/LVN to provide?

• A. Anywhere you want to stand as long as you do not get hurt by those in the parade.
• B. You are confused because of all the activity in the hall. There is no parade.
• C. Let us go back to the activity room and see what is going on in there.
• D. Remember I told you that this is a nursing home and I am your nurse.

Correct answer: C

Rationale: Redirecting the client to a less confusing environment can help reduce anxiety and reorient her to reality.

3. A female client with major depression is prescribed fluoxetine (Prozac). She reports experiencing increased energy but still feels sad and hopeless. What is the nurse's best response?

• A. ''These feelings are normal and will pass with time.''
• B. ''Increased energy can sometimes lead to increased risk for self-harm.''
• C. ''The medication needs more time to be effective.''
• D. ''Let's talk about the things that make you feel this way.''

Correct answer: B

Rationale: The correct answer is B. Increased energy without improvement in mood can increase the risk of self-harm in clients with depression. It is crucial for the nurse to recognize this potential risk and closely monitor the client for any signs of self-harm. Choice A is incorrect because dismissing the client's persistent feelings of sadness and hopelessness as normal may invalidate her experiences. Choice C is incorrect as fluoxetine (Prozac) typically starts showing effectiveness within a few weeks, so further delay is concerning. Choice D is incorrect because while discussing the client's feelings is important, the immediate focus should be on addressing the potential risk of self-harm associated with increased energy.

4. A male client who has been on lithium therapy for 5 years is experiencing frequent urination and increased thirst. What should the nurse's next action be?

• A. Instruct the client to increase fluid intake.
• B. Assess for signs of lithium toxicity.
• C. Suggest the client reduce salt intake.
• D. Notify the healthcare provider immediately.

Correct answer: B

Rationale: Frequent urination and increased thirst can be signs of lithium toxicity, which can lead to serious complications if not addressed promptly. Assessing for signs of lithium toxicity is crucial to determine the client's condition and prevent further harm. Instructing the client to increase fluid intake (Choice A) may worsen the situation by exacerbating lithium toxicity. Suggesting the client reduce salt intake (Choice C) is not the priority when signs of toxicity are present. Notifying the healthcare provider immediately (Choice D) is important, but the initial action should be to assess the client for signs of lithium toxicity to provide immediate care.

5. A nurse working in the emergency room of a children's hospital admits a child whose injuries could have resulted from abuse. Which statement most accurately describes the nurse's responsibility in cases of suspected child abuse?

• A. Obtain objective data such as x-rays before reporting suspicions.
• B. Confirm suspicions of abuse with the physician.
• C. Report any case of suspected child abuse.
• D. Document injuries to confirm suspected abuse.

Correct answer: C

Rationale: The correct answer is C: 'Report any case of suspected child abuse.' Nurses are mandated reporters, which means they are legally obligated to report any suspicions of child abuse to appropriate authorities to ensure the child's safety. This responsibility overrides the need to gather additional data or confirm suspicions with others before reporting. Choice A is incorrect because delaying reporting to gather more data may risk the child's safety. Choice B is incorrect because reporting suspicions promptly is crucial, and waiting to confirm with another healthcare provider could delay necessary intervention. Choice D is incorrect as the priority is to report suspicions promptly rather than focusing on documenting injuries to confirm abuse.

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