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 RN is providing care for a client diagnosed with borderline personality disorder who has self-inflicted lacerations on the abdomen. Which approach should the RN use when changing this client's dressing?

• A. Provide detailed explanations during wound cleansing.
• B. Perform the dressing change in a non-judgmental manner.
• C. Ask the client non-threateningly why they cut their abdomen.
• D. Request assistance from another staff member for the dressing change.

Correct answer: B

Rationale: Performing the dressing change in a non-judgmental manner is crucial when caring for a client with borderline personality disorder who has self-inflicted injuries. This approach helps build trust, reduces feelings of shame or guilt, and fosters a therapeutic relationship. Choice A is incorrect because while detailed explanations may be necessary, the focus should be on the non-judgmental approach. Choice C is inappropriate as it may come across as accusatory or threatening, potentially worsening the client's emotional state. Choice D is not the best option as the RN should strive to handle the situation themselves in a supportive and empathetic manner.

3. A nurse is providing discharge teaching to a client with schizophrenia who is prescribed clozapine (Clozaril). Which information should the nurse include?

• A. You need to come in for regular blood tests.
• B. This medication can cause weight loss.
• C. You can stop taking this medication once you feel better.
• D. Avoid foods high in tyramine while on this medication.

Correct answer: A

Rationale: The correct answer is A: 'You need to come in for regular blood tests.' Clozapine can cause agranulocytosis, a potentially life-threatening condition, so regular blood tests are required to monitor the client's white blood cell count. Choice B is incorrect because clozapine is associated with weight gain, not weight loss. Choice C is incorrect because the client should never stop taking clozapine abruptly due to the risk of withdrawal symptoms and symptom relapse. Choice D is incorrect because avoiding foods high in tyramine is typically associated with MAOIs, not clozapine.

4. A male client is brought to the emergency department by a police officer, who reports the client was disturbing the peace by running naked in the street, striking out at others, and smashing car windows. Which behaviors should the client demonstrate to determine if he should be evaluated for involuntary commitment?

• A. Threats to kill his friend.
• B. Disruptive behaviors in a community setting.
• C. Hears voices telling him to kill himself.
• D. Reports he has not needed a bath in 4 months.

Correct answer: D

Rationale: The client's dangerous and disruptive behaviors, along with auditory hallucinations of self-harm, suggest a need for involuntary commitment for his safety and that of others. Involuntary commitment may be warranted based on the client's poor hygiene and self-neglect, as it indicates an inability to care for himself, which can pose a risk to his well-being.

5. The nurse is admitting a male client who takes lithium carbonate (Eskalith) twice a day. Which information should the nurse report to the healthcare provider immediately?

• A. Short-term memory loss.
• B. Depressed affect.
• C. Five-pound weight gain.
• D. Nausea and vomiting.

Correct answer: D

Rationale: Nausea and vomiting should be reported immediately because they could indicate lithium toxicity, which requires urgent medical attention to prevent more severe effects. Short-term memory loss, depressed affect, and weight gain are common side effects of lithium but do not require immediate medical attention compared to symptoms of toxicity like nausea and vomiting.

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