Nursing Elites

1. A female client with anorexia nervosa is admitted to the hospital. What is the priority assessment for the nurse to perform?

• A. Assess the client's body image perception.
• B. Monitor the client's electrolyte levels.
• C. Evaluate the client's exercise habits.
• D. Assess the client's relationship with her family.

Correct answer: B

Rationale: The correct answer is to monitor the client's electrolyte levels. In clients with anorexia nervosa, electrolyte imbalances can lead to serious, potentially life-threatening complications such as cardiac arrhythmias. Assessing body image perception (choice A) is important but not the priority when compared to monitoring electrolyte levels. Evaluating exercise habits (choice C) and assessing the client's relationship with her family (choice D) are also important aspects of care but do not take precedence over monitoring electrolyte levels in a client with anorexia nervosa.

2. When developing a plan of care for a client in the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing diagnosis has the highest priority?

• A. Risk for injury.
• B. Ineffective coping mechanisms.
• C. Alteration in comfort.
• D. Ineffective breathing patterns.

Correct answer: D

Rationale: When a client aspirates a caustic material, the priority nursing diagnosis should focus on addressing physiological concerns, particularly related to breathing patterns. Aspiration of caustic material can lead to airway compromise, respiratory distress, and potential lung damage. Therefore, monitoring and addressing ineffective breathing patterns are crucial for ensuring the client's immediate safety and well-being. Choices A, B, and C are important considerations in psychiatric care but are secondary to the critical physiological issue of ineffective breathing patterns in this scenario.

3. A client with bipolar disorder is prescribed valproic acid (Depakote). What is the most important laboratory test for the LPN/LVN to monitor?

• A. Liver function tests.
• B. Kidney function tests.
• C. Thyroid function tests.
• D. Complete blood count.

Correct answer: A

Rationale: The correct answer is A: Liver function tests. Monitoring liver function tests is crucial for clients prescribed valproic acid (Depakote) due to the medication's potential to affect liver function and increase the risk of liver toxicity. While kidney function tests (choice B), thyroid function tests (choice C), and complete blood count (choice D) are important in various clinical scenarios, the priority when administering valproic acid is to monitor liver function to prevent adverse effects associated with this medication.

4. Physical examination of a 6-year-old reveals several bite marks in various locations on his body. X-ray examination reveals healed fractures of the ribs. The mother tells the nurse that her child is always having accidents. Which initial response by the nurse is most appropriate?

• A. I need to inform the healthcare provider about your child's tendency to be accident-prone.
• B. Tell me more specifically about your child's accidents.
• C. I must report these injuries to the authorities because they do not seem accidental.
• D. Boys this age always seem to require more supervision and can be quite accident-prone.

Correct answer: B

Rationale: (B) seeks more information in a non-threatening manner to gather additional details about the child's accidents. This response allows the nurse to explore the situation further without making assumptions. (A) fails to address the concerning findings and instead focuses on informing the healthcare provider. (C) jumps to conclusions without gathering more information, potentially causing unnecessary distress to the family. (D) dismisses the seriousness of the situation by attributing the injuries to common accidents for boys, missing the opportunity to delve deeper into the issue.

5. The nurse is conducting discharge teaching for a client with schizophrenia who plans to live in a group home. Which statement is most indicative of the need for careful follow-up after discharge?

• A. Crickets are a good source of protein.
• B. I have not heard any voices for a week.
• C. Only my belief in God can help me.
• D. Sometimes I have a hard time sitting still.

Correct answer: C

Rationale: The correct answer is C. The statement 'Only my belief in God can help me' suggests a reliance on spiritual intervention over medical treatment, raising concerns about potential non-compliance. This indicates the need for close follow-up to ensure the client's well-being and adherence to the prescribed treatment plan. Choices A, B, and D do not directly address potential issues related to treatment compliance or the need for follow-up care after discharge.

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