Nursing Elites

1. During the manic phase of bipolar disorder, what is the priority nursing intervention for a female client who has not slept for the past 48 hours, is hyperactive, talkative, and engaging in risky behaviors?

• A. Encourage the client to participate in a quiet activity.
• B. Provide a safe environment and limit stimuli.
• C. Administer a sedative to help the client sleep.
• D. Discuss the consequences of her risky behaviors.

Correct answer: B

Rationale: The correct priority nursing intervention for a female client in the manic phase of bipolar disorder, who has not slept for 48 hours, is hyperactive, talkative, and engaging in risky behaviors, is to provide a safe environment and limit stimuli. This approach is crucial to prevent harm to the client and others. Encouraging a quiet activity (Choice A) may not effectively address the need for safety during the manic phase. Administering a sedative (Choice C) should be done under the guidance of a healthcare provider and does not address the immediate safety concerns. Discussing consequences of risky behaviors (Choice D) may not be effective during the manic phase when the client's judgment is impaired.

2. 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.

3. 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.

4. Unresolved feelings related to loss are most likely to be recognized during which phase of the therapeutic nurse-client relationship?

• A. Working
• B. Trusting
• C. Orientation
• D. Termination

Correct answer: D

Rationale: Unresolved feelings related to loss are often recognized and explored during the termination phase of the nurse-client relationship. This phase involves preparing the client for separation from the nurse, which can trigger unresolved feelings related to loss. During the termination phase, clients may confront their emotions about ending the therapeutic relationship and may also revisit unresolved issues or losses that have surfaced during the course of therapy. Choices A, B, and C are incorrect because the working phase focuses on active problem-solving and goal achievement, the trusting phase emphasizes establishing rapport and building trust, and the orientation phase involves initial introductions and orientation to the therapeutic process, respectively.

5. An emergency department nurse is caring for an adult client who is a victim of family violence. Which priority instruction would be included in the discharge instructions?

• A. Information regarding shelters
• B. Instructions regarding calling the police
• C. Instructions regarding self-defense classes
• D. Explaining the importance of leaving the violent situation

Correct answer: A

Rationale: The correct answer is A: Information regarding shelters. Providing information about shelters is crucial in cases of family violence as it ensures the client has a safe place to go after discharge, prioritizing their immediate safety. Option B, instructions regarding calling the police, may be necessary but ensuring a safe place to stay is more immediate. Option C, instructions regarding self-defense classes, may not be appropriate as the priority is to ensure the client's safety rather than teaching self-defense. Option D, explaining the importance of leaving the violent situation, is relevant but providing information on immediate shelter options is the priority.

Similar Questions