Nursing Elites

1. A client states that she hears God's voice telling her that she has sinned and needs to punish herself. Which response by the LPN/LVN is most important?

• A. How do you think you will be punished?
• B. Please tell staff when you think you need to punish yourself.
• C. What exactly do you think you have done to be punished?
• D. Let's talk about your strengths

Correct answer: B

Rationale: The most important response by the LPN/LVN is to encourage the client to communicate with staff when they feel the need to punish themselves. This approach can help assess the risk of self-harm and enable appropriate intervention. Choice A focuses more on the method of punishment rather than encouraging help-seeking behavior. Choice C seeks specific details about the perceived wrongdoing rather than addressing the immediate concern of self-punishment. Choice D, discussing strengths, does not directly address the client's current distress and potential self-harm risk.

2. An adolescent who attempted suicide with a drug overdose arrives in the emergency department with an empty 30-tablet bottle of acetaminophen (Tylenol). Which action should the nurse implement?

• A. Administer acetylcysteine (Mucomyst).
• B. Monitor cardiac rhythm for flat T waves.
• C. Check both serum AST and ALT levels.
• D. Prepare to administer Syrup of Ipecac.

Correct answer: A

Rationale: The correct action for the nurse to implement is to administer acetylcysteine (Mucomyst). Acetylcysteine is the antidote for acetaminophen overdose and should be administered promptly to prevent liver damage. Monitoring cardiac rhythm for flat T waves (Choice B) is not specific to acetaminophen overdose and is more related to cardiac conditions. Checking serum AST and ALT levels (Choice C) may be done later but is not the initial priority in this situation. Similarly, preparing to administer Syrup of Ipecac (Choice D) is not recommended anymore in cases of overdose as it can cause more harm.

3. A client with schizophrenia is being discharged with a prescription for risperidone (Risperdal). What is the most important instruction for the nurse to provide?

• A. Stop taking the medication if you start feeling better.
• B. Be aware of the potential for weight gain with this medication.
• C. Report any unusual muscle movements immediately.
• D. You can drive as soon as you feel ready.

Correct answer: C

Rationale: The correct answer is C: "Report any unusual muscle movements immediately." Unusual muscle movements may indicate extrapyramidal symptoms (EPS) or tardive dyskinesia, which are serious side effects of antipsychotic medications like risperidone. It is crucial to address these symptoms promptly to prevent long-term effects. Choice A is incorrect because stopping the medication suddenly can be dangerous and should only be done under medical supervision. Choice B, while important, is not the most critical instruction in this scenario. Choice D is also incorrect as the ability to drive may be affected by the medication and should be discussed with a healthcare provider.

4. How should the RN respond to the mother?

• A. Ask the mother if she has ever thought about harming herself or her child.
• B. Reassure the mother that her child will achieve some growth and development milestones.
• C. Determine if the mother has other children who do not have developmental disabilities.
• D. Encourage the mother to write her thoughts and feelings in a journal.

Correct answer: A

Rationale: The correct response is to ask the mother if she has ever thought about harming herself or her child. This is crucial to assess for suicidal or homicidal thoughts, ensuring the safety of both the mother and the child. Reassuring the mother about achieving some milestones may not address her immediate emotional distress. Inquiring about other children's developmental status is not the priority when safety concerns are present. While journaling can be therapeutic, in this situation, addressing safety takes precedence.

5. What is the most important goal of care for a client diagnosed with generalized anxiety disorder (GAD) who has been taking the benzodiazepine alprazolam (Xanax) long-term? The client will:

• A. Describe a decrease in anxiety using a 1 to 10 anxiety scale.
• B. State the importance of not abruptly stopping the medication.
• C. Not experience dizziness, lightheadedness, or sedation.
• D. Attend scheduled individual and group therapy sessions.

Correct answer: B

Rationale: The correct answer is B. The most important goal of care for a client with generalized anxiety disorder (GAD) taking alprazolam long-term is to ensure they understand the importance of not abruptly stopping the medication. Abruptly stopping benzodiazepines can lead to withdrawal symptoms and potential complications. Choice A is not the most critical goal as the focus should be on the safe continuation of the medication. Choice C is important but not as crucial as preventing abrupt discontinuation. Choice D is beneficial for overall treatment but not the most important goal in this scenario.

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