Nursing Elites

1. A client with a leg amputation is upset about his appearance. The LPN/LVN intends to address which most closely associated psychosocial problem?

• A. Inability to be mobile
• B. Isolating self from others
• C. Inability to tolerate activity
• D. Concern about body persona

Correct answer: D

Rationale: The correct answer is D. A client with a leg amputation being upset about his appearance is most closely associated with concerns about body image and self-perception. This individual may be worried about how others perceive them, impacting their self-esteem and overall well-being. Choices A, B, and C are incorrect because the primary psychosocial issue in this scenario is related to body image and self-perception, not mobility, social isolation, or activity tolerance.

2. 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.

3. During an annual physical by the occupational nurse working in a corporate clinic, a male employee tells the nurse that his high-stress job is causing trouble in his personal life. He further explains that he often gets so angry while driving to and from work that he has considered 'getting even' with other drivers. How should the nurse respond?

• A. Anger is contagious and could result in major confrontation.
• B. Try not to let your anger cause you to act impulsively.
• C. Expressing your anger to a stranger could result in an unsafe situation.
• D. It sounds as if you feel angry for no reason

Correct answer: C

Rationale: The correct responses are C and D. The nurse should acknowledge the employee's feelings of anger and suggest that expressing anger to strangers, like other drivers, could lead to unsafe situations. This response aims to prevent potential confrontations or harm. Choice A is incorrect as it doesn't address the specific situation of expressing anger while driving. Choice B is also incorrect as it is vague and doesn't provide practical advice to manage the anger effectively.

4. The nurse documents that a male client with paranoid schizophrenia is delusional. Which statement by the client confirms this assessment?

• A. The voices are telling me to kill the next person I see.
• B. The fire is burning my skin away right now.
• C. The snakes on the wall are going to eat me.
• D. The nurse at night is trying to poison me with pills.

Correct answer: D

Rationale: The correct answer is D. Believing that the nurse is trying to poison him with pills is a clear indication of delusional paranoia, a common symptom in paranoid schizophrenia. Choices A, B, and C do not directly relate to paranoid delusions and are more indicative of hallucinations or other forms of delusions not specific to paranoia.

5. The client is planning discharge for a male client with schizophrenia. The client insists that he is returning to his apartment, although the healthcare provider informed him that he will be moving to a boarding home. What is the most important nursing diagnosis for discharge planning?

• A. Ineffective denial related to situational anxiety.
• B. Ineffective coping related to inadequate support.
• C. Social isolation related to difficult interactions.
• D. Self-care deficit related to cognitive impairment.

Correct answer: A

Rationale: The best nursing diagnosis is (A) because the client is unable to acknowledge the move to a boarding home. While (B, C, and D) are potential nursing diagnoses, denial is the most critical as it is a defense mechanism preventing the client from addressing his feelings regarding the change in living arrangements.

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