Nursing Elites

1. In the described scenario, a manic client threatens a nurse with physical violence after being told they cannot have a stripper perform. What is the most appropriate action for the LPN/LVN to take?

• A. Orient the client to time, person, and place
• B. Tell the client that the behavior is inappropriate
• C. Escort the manic client to her room, with assistance
• D. Tell the client that smoking privileges are revoked for 24 hours

Correct answer: C

Rationale: In this situation, where the manic client becomes verbally abusive and threatens physical violence, the most appropriate action for the LPN/LVN is to escort the client to her room with assistance. This action helps ensure the safety of both the client and the nurse, while also providing a controlled environment that can help de-escalate the situation. Choices A and B do not address the immediate safety concerns presented by the client's behavior. Choice D, revoking smoking privileges, is not directly related to the client's current behavior and does not address the threat of violence.

2. The nurse is planning care for a 32-year-old male client diagnosed with HIV infection who has a history of chronic depression. Recently, the client's viral load has begun to increase rather than decrease despite his adherence to the HIV drug regimen. What should the nurse do first while taking the client's history upon admission to the hospital?

• A. Determine if the client attends a support group weekly.
• B. Hold all antidepressant medications until further notice.
• C. Ask the client if he takes St. John's Wort routinely.
• D. Have the client describe any recent changes in mood.

Correct answer: C

Rationale: The nurse's top priority upon admission is to determine if the client has been taking St. John's Wort, an herbal preparation often used for depression. St. John's Wort can interact adversely with medications used to treat HIV infection, potentially explaining the rise in the viral load (C). Asking about attending support groups (A) or recent changes in mood (D) may provide valuable information about the client's depression but is not as critical as determining St. John's Wort use. Holding antidepressant medications (B) without assessing for potential interactions can be harmful to the client.

3. A male client with schizophrenia who is taking fluphenazine decanoate (Prolixin decanoate) is being discharged in the morning. A repeat dose of medication is scheduled for 20 days after discharge. The client tells the nurse that he is going on vacation in the Bahamas and will return in 18 days. Which statement by the client indicates a need for health teaching?

• A. "When I return from my tropical island vacation, I will go to the clinic to get my Prolixin injection."
• B. "While I am on vacation and when I return, I will not consume any alcohol-containing food or beverages."
• C. "I will inform the healthcare provider if I develop a sore throat or flu-like symptoms."
• D. "I will maintain my daily intake of benztropine mesylate (Cogentin)."

Correct answer: A

Rationale: Photosensitivity is a side effect of Prolixin, and a vacation in the Bahamas (with its tropical island climate) increases the client's risk of experiencing this side effect. Therefore, the client should be advised to avoid direct sun exposure. Choice A indicates a need for health teaching as the client plans to return from vacation in 18 days, which is earlier than the scheduled dose of Prolixin at 20 days after discharge. Choices B, C, and D demonstrate accurate knowledge. Choice B is important because alcohol can interact with Prolixin. Choice C is relevant as it mentions signs of agranulocytosis, a potential side effect of Prolixin. Choice D is correct as benztropine mesylate is used to prevent extrapyramidal symptoms associated with Prolixin.

4. Which information should the LPN/LVN exclude in the nursing plan of care for a client with obsessive-compulsive disorder (OCD)?

• A. The medical diagnosis of the client
• B. Individualized goals and objectives
• C. Attendance at group therapy sessions
• D. Self-care measures to improve hygiene

Correct answer: A

Rationale: The correct answer is A because including the medical diagnosis of the client in the nursing plan is redundant as the healthcare team is already aware of the diagnosis. The nursing plan of care for a client with OCD should focus on individualized goals, objectives, attendance at group therapy sessions, and self-care measures to improve hygiene. These components directly contribute to addressing the client's needs and promoting recovery. Therefore, the medical diagnosis does not need to be included in the nursing plan as it does not actively guide the day-to-day care and interventions for the client.

5. The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. What information should the nurse explore in depth with the client based on this screening tool?

• A. Cancer screening results, anger, gastritis, daily alcohol intake.
• B. Efforts to cut down, annoyance with questions, guilt, drinking as an 'Eye-opener.'
• C. Consumption, liver enzyme, gastrointestinal complaints and bleeding.
• D. Minimizes drinking, frequently misses family events, guilt about drinking, amount of daily intake.

Correct answer: B

Rationale: The CAGE questionnaire is used to identify problematic drinking behaviors. Choice B is correct because it includes key aspects that the nurse should explore further with the client. 'Efforts to cut down' can indicate acknowledgment of excessive drinking, 'guilt' reflects emotional distress related to drinking, and 'drinking as an 'Eye-opener'' suggests potential dependency. Choices A, C, and D are incorrect as they do not directly address the essential elements assessed by the CAGE questionnaire and may not provide relevant information for further evaluation of the client's drinking habits.

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