Nursing Elites

1. A client is admitted to the mental health unit and reports taking extra anti-anxiety medication because, 'I'm so stressed out. I just wanted to go to sleep.' The nurse should plan one-on-one observation of the client based on which statement?

• A. What should I do? Nothing seems to help.
• B. I have been so tired lately and needed to sleep.
• C. I really think that I don't need to be here.
• D. I don't want to talk. Nothing matters anymore.

Correct answer: D

Rationale: The correct answer is D because expressing feelings of hopelessness or nihilism can be indicators of a deeper, possibly dangerous level of depression. Choice A is incorrect as it indicates seeking help, Choice B suggests fatigue, and Choice C implies denial of needing help, none of which directly signify severe depression warranting one-on-one observation.

2. A client with obsessive-compulsive disorder (OCD) spends hours each day washing their hands. Which nursing intervention is most appropriate initially?

• A. Allow the client to continue the behavior to reduce anxiety.
• B. Set strict limits on the time allowed for handwashing.
• C. Distract the client with other activities.
• D. Encourage the client to participate in a support group.

Correct answer: A

Rationale: Initially, it is most appropriate to allow the client to continue the behavior to reduce anxiety (A). For clients with OCD, abruptly stopping compulsive behaviors can lead to increased anxiety and distress. Setting strict limits (B) may exacerbate anxiety at first. Distraction with other activities (C) may not address the underlying issue effectively. While support groups (D) can be beneficial, they are typically introduced after establishing trust and gradually working on reducing compulsive behaviors.

3. 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.

4. A client with bipolar disorder is being treated with lithium. The nurse should monitor the client for which early sign of lithium toxicity?

• A. Diarrhea
• B. Tremors
• C. Polyuria
• D. Blurred vision

Correct answer: A

Rationale: Corrected Rationale: Diarrhea is an early sign of lithium toxicity. When a client being treated with lithium presents with diarrhea, it can indicate the beginning of lithium toxicity. Monitoring for this symptom is crucial as it can progress to more severe toxicity if not addressed promptly. Tremors (choice B) are more commonly associated with the therapeutic effects of lithium rather than toxicity. Polyuria (choice C) is a common side effect of lithium, but it is not typically an early sign of toxicity. Blurred vision (choice D) is not a common early sign of lithium toxicity. Therefore, option A is the correct answer.

5. A client with schizophrenia is experiencing auditory hallucinations that command him to harm himself. What is the nurse's priority action?

• A. Ensure the client is not left alone.
• B. Document the content of the hallucinations.
• C. Administer PRN antipsychotic medication.
• D. Encourage the client to ignore the voices.

Correct answer: A

Rationale: The correct answer is to ensure the client is not left alone. When a client with schizophrenia is having auditory hallucinations that command self-harm, the priority is to ensure the client's safety. Leaving the client alone may increase the risk of self-harm. Documenting the content of the hallucinations (choice B) is important but not the priority when immediate safety is a concern. Administering PRN antipsychotic medication (choice C) may be necessary but is not the priority over ensuring the client's immediate safety. Encouraging the client to ignore the voices (choice D) is not as effective as ensuring the client's safety by being present and providing support.

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