Nursing Elites

1. A male adolescent is admitted with bipolar disorder after being released from jail for assault with a deadly weapon. When the nurse asks the teen to identify his reason for the assault, he replies, 'Because he made me mad!' Which goal is best for the nurse to include in the client's plan of care? The client will

• A. outline methods for managing anger.
• B. control impulsive actions toward self and others.
• C. verbalize feelings when anger occurs.
• D. recognize consequences for behaviors exhibited.

Correct answer: B

Rationale: In this scenario, the client's response indicates poor impulse control, a common issue in individuals with bipolar disorder. The most critical goal for the nurse to include in the client's plan of care is to help the client control impulsive actions toward self and others. This goal is essential for preventing harmful behaviors and mitigating the social consequences associated with impulsivity. While outlining methods for managing anger, verbalizing feelings when anger occurs, and recognizing consequences for behaviors exhibited are important aspects of therapy, they do not directly address the urgent need to control impulsive behavior in this case.

2. A nurse working in a psychiatric unit is assessing a client who appears to be responding to internal stimuli. The client is laughing and talking to himself. What is the nurse's best initial response?

• A. Approach the client and ask if he is hearing voices.
• B. Ignore the behavior as it is common in psychiatric settings.
• C. Encourage the client to express his thoughts verbally.
• D. Observe the client's behavior from a distance.

Correct answer: A

Rationale: Approaching the client and asking if he is hearing voices is the best initial response by the nurse. This action can help assess the situation and determine if the client is experiencing hallucinations that may require immediate intervention. Choice B is incorrect because ignoring the behavior could lead to missing important signs of distress or potential risks. Choice C may not address the immediate concern of assessing for hallucinations. Choice D is also not ideal as observing from a distance may not provide the necessary information for immediate assessment and intervention.

3. The LPN/LVN should include which interventions in the plan of care for a severely depressed client with neurovegetative symptoms? (select one that does not apply.)

• A. Permit rest periods as needed.
• B. Speaking slowly and simply.
• C. Place the client on suicide precautions.
• D. Limit and discourage food and fluid intake.

Correct answer: D

Rationale: For a severely depressed client with neurovegetative symptoms, the care plan should include rest, simple communication, suicide precautions, monitoring intake, and encouraging mild exercise. Limiting and discouraging food and fluid intake is not appropriate as proper nutrition and hydration are essential for overall well-being. This choice could lead to further complications and is not recommended in the care of a depressed client.

4. A nurse is caring for a client with major depressive disorder who is withdrawn and refuses to participate in group activities. What is the best nursing intervention?

• A. Encourage the client to attend at least one group session.
• B. Respect the client's wish to remain isolated.
• C. Arrange for individual therapy sessions.
• D. Offer the client a list of activities to choose from.

Correct answer: A

Rationale: Encouraging the client to attend at least one group session is the best nursing intervention in this scenario. By gently encouraging participation, the nurse can help the client start to engage with others, which may gradually improve their mood and social interaction. Choice B, respecting the client's wish to remain isolated, may further exacerbate the client's withdrawal and depression by reinforcing avoidance behavior. Choice C, arranging for individual therapy sessions, can be beneficial but may not address the specific need for social interaction. Choice D, offering a list of activities to choose from, does not directly address the client's difficulty in participating in group activities and may not provide the necessary support in overcoming social withdrawal.

5. The nurse asks a female client with borderline personality disorder, 'How do you feel about your children not coming to visit this weekend?' The client looks out the window and replies, 'I really don't care.' Which response is best for the nurse to provide?

• A. I noticed you were looking out the window when discussing your feelings.
• B. I think you're lying and it bothers you that your children aren't coming.
• C. I think you should discuss your children not coming in the group meeting.
• D. Why do you think your children didn't want to come visit you this weekend?

Correct answer: A

Rationale: Acknowledging the client's non-verbal behavior, such as looking out the window, demonstrates active listening and provides the client with an opportunity to explore their feelings further. Choice B is incorrect as it accuses the client of lying without any evidence, which can damage the therapeutic relationship. Choice C is inappropriate as it dismisses the client's feelings and suggests a group discussion without addressing the client's emotions directly. Choice D is also incorrect as it focuses on the children's actions rather than the client's feelings, missing an opportunity for therapeutic communication.

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