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. A client with obsessive-compulsive disorder (OCD) is hospitalized for treatment. Which intervention is most important for the LPN/LVN to include in the client's plan of care?

• A. Allow the client to engage in compulsive behaviors as a way to reduce anxiety.
• B. Encourage the client to ignore the compulsive behaviors.
• C. Help the client to understand the purpose of compulsive behaviors.
• D. Work with the client to gradually reduce the frequency of compulsive behaviors.

Correct answer: D

Rationale: The correct intervention for a client with OCD is to work with them to gradually reduce the frequency of compulsive behaviors. This approach helps the client manage their condition effectively without causing undue distress. Allowing the client to engage in compulsive behaviors can reinforce the disorder rather than alleviate it. Encouraging the client to ignore compulsive behaviors does not address the core issue of OCD. While helping the client understand the purpose of compulsive behaviors can be beneficial, actively working to reduce these behaviors is more crucial in the treatment of OCD.

3. A nurse is assessing a client with dementia who is showing signs of increased confusion and agitation in the late afternoon. What is the most likely explanation for the client's symptoms?

• A. Anxiety
• B. Depression
• C. Sun-downing syndrome
• D. Medication side effects

Correct answer: C

Rationale: The correct answer is C: Sun-downing syndrome. Sun-downing syndrome is a phenomenon commonly seen in individuals with dementia, where they exhibit increased confusion and agitation in the late afternoon or evening. This pattern of behavior is believed to be linked to disruptions in the circadian rhythm and can be triggered by factors such as fatigue, low lighting, or increased shadows during the evening. Choices A and B, anxiety and depression, may be comorbid conditions in individuals with dementia but are not the primary explanation for the symptoms described. While medication side effects (Choice D) should always be considered in a client with dementia, given the time-specific nature of the symptoms, sun-downing syndrome is the most likely explanation in this case.

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. The client with schizophrenia believes the news commentator is her lover and speaks to her. What is the best response for the nurse to make?

• A. What do you believe the news commentator said to you?
• B. Let's switch to a different news channel.
• C. Is the news commentator planning to harm you or others?
• D. The news commentator is not communicating with you.

Correct answer: A

Rationale: The correct response is to ask the client what she believes the news commentator said, as it helps the nurse assess the client's perception and delve into her delusions without being confrontational. Choice B is not helpful in addressing the client's delusions. Choice C jumps to conclusions about potential harm without assessing the client's beliefs. Choice D is dismissive and does not address the client's reality.

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