Nursing Elites

1. A male client with alcohol use disorder is admitted for detoxification. The nurse knows that which symptom is a sign of severe alcohol withdrawal?

• A. Bradycardia
• B. Seizures
• C. Hyperglycemia
• D. Constipation

Correct answer: B

Rationale: Seizures are a sign of severe alcohol withdrawal and can be life-threatening, requiring immediate medical attention. Bradycardia, hyperglycemia, and constipation are not typically associated with severe alcohol withdrawal. Bradycardia is more commonly seen in opioid withdrawal, hyperglycemia could be due to other reasons like uncontrolled diabetes, and constipation is not a typical symptom of severe alcohol withdrawal.

2. The RN is preparing to administer a prescribed dose of haloperidol (Haldol) to a client with schizophrenia. The client begins to exhibit muscle rigidity, fever, and altered mental status. What action should the RN take first?

• A. Administer the haloperidol as prescribed.
• B. Monitor the client's vital signs closely.
• C. Hold the medication and notify the healthcare provider.
• D. Give the client an antipyretic for the fever.

Correct answer: C

Rationale: Muscle rigidity, fever, and altered mental status are symptoms of neuroleptic malignant syndrome (NMS), a potentially life-threatening reaction to antipsychotic medications. The RN should hold the medication and notify the healthcare provider immediately. Option A is incorrect because administering more of the medication can worsen the symptoms. Option B is not the first priority when the client is experiencing symptoms of NMS. Option D is incorrect as addressing the fever alone does not address the underlying issue of NMS caused by haloperidol.

3. Which client outcome indicates improvement for a client who is admitted with auditory hallucinations?

• A. Argues with the voices.
• B. Tells when voices decrease.
• C. Follows what the voices say.
• D. Tells the nurse what the voices say.

Correct answer: B

Rationale: The correct answer is B: 'Tells when voices decrease.' This outcome indicates improvement because it shows that the client is experiencing a reduction in auditory hallucinations. By communicating that the voices are decreasing, it suggests that the client's symptoms are improving and the treatment is effective. Choices A, C, and D are incorrect. Arguing with the voices (A) indicates ongoing engagement with the hallucinations, which is not a positive outcome. Following what the voices say (C) suggests compliance with the hallucinations, which is not indicative of improvement. Lastly, telling the nurse what the voices say (D) does not necessarily demonstrate a reduction in hallucinations or improvement in the client's condition.

4. The LPN/LVN is caring for a client with post-traumatic stress disorder (PTSD). Which intervention is most appropriate for the nurse to implement?

• A. Encourage the client to talk about the traumatic event.
• B. Assist the client in developing coping strategies.
• C. Refer the client to a PTSD support group.
• D. Administer prescribed medications to manage symptoms.

Correct answer: B

Rationale: Assisting the client in developing coping strategies is an appropriate intervention for managing PTSD. This approach helps the client build resilience and learn how to effectively cope with symptoms. Choice A, encouraging the client to talk about the traumatic event, may not be appropriate as it can potentially re-traumatize the client. Referring the client to a PTSD support group, as in choice C, can be beneficial but may not be the most immediate intervention. Administering medications, as in choice D, is important in some cases, but focusing on coping strategies should be prioritized as a holistic approach to managing PTSD.

5. 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.

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