Nursing Elites

1. A client with post-traumatic stress disorder (PTSD) is experiencing a flashback. What is the nurse's priority action?

• A. Encourage the client to talk about the trauma.
• B. Help the client to focus on the present.
• C. Administer prescribed anti-anxiety medication.
• D. Leave the client alone to work through the flashback.

Correct answer: B

Rationale: The priority action is to help the client focus on the present (B), which can reduce the intensity of the flashback. Encouraging discussion of the trauma (A) should be done when the client is not actively experiencing a flashback. While medication (C) may be necessary, it is not the first priority in this situation. Leaving the client alone (D) is not appropriate as they need support to manage the flashback.

2. A LVN/LPN is caring for a client with anorexia nervosa. The nurse is monitoring the behavior of the client and understands that a client with anorexia nervosa manages anxiety by:

• A. Engaging in immoral acts
• B. Always reinforcing self-approval
• C. Observing rigid rules and regulations
• D. Having the need always to make the right decision

Correct answer: C

Rationale: Clients with anorexia nervosa often manage anxiety by adhering strictly to rules and regulations as a way to maintain control. Choice A is incorrect because engaging in immoral acts is not a common coping mechanism for clients with anorexia nervosa. Choice B is incorrect as self-approval is not typically the primary way clients with anorexia nervosa manage anxiety. Choice D is incorrect because while clients with anorexia nervosa may have a need to make the right decision, it is not the primary way they manage their anxiety.

3. The nurse is admitting a male client who takes lithium carbonate (Eskalith) twice a day. Which information should the nurse report to the healthcare provider immediately?

• A. Short-term memory loss.
• B. Depressed affect.
• C. Five-pound weight gain.
• D. Nausea and vomiting.

Correct answer: D

Rationale: Nausea and vomiting should be reported immediately because they could indicate lithium toxicity, which requires urgent medical attention to prevent more severe effects. Short-term memory loss, depressed affect, and weight gain are common side effects of lithium but do not require immediate medical attention compared to symptoms of toxicity like nausea and vomiting.

4. 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.

5. A client with schizophrenia is admitted to the psychiatric care unit for aggressive behavior, auditory hallucinations, and potential for self-harm. The client has not been taking medications as prescribed and insists that the food has been poisoned and refuses to eat. What intervention should the RN implement?

• A. Assure the client that all food served in the hospital is safe to eat.
• B. Tell the client that irrational thinking is a symptom of schizophrenia.
• C. Obtain an order for a tube feeding for the client.
• D. Provide the client with food in unopened containers.

Correct answer: D

Rationale: The correct intervention is to provide the client with food in unopened containers. This approach can help alleviate the client's fear of poisoning and encourage eating. Choice A may not address the client's specific fear and may be perceived as dismissive. Choice B, while providing information about symptoms of schizophrenia, does not address the immediate issue of the client's refusal to eat due to the fear of poisoning. Choice C of obtaining an order for tube feeding is premature and invasive before exploring less restrictive options.

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