Nursing Elites

1. A nurse working on a mental health unit receives a community call from a person who is tearful and states, 'I just feel so nervous all of the time. I don't know what to do about my problems. I haven't been able to sleep at night and have hardly eaten for the past 3 or 4 days.' The nurse should initiate a referral based on which assessment?

• A. Altered thought processes.
• B. Moderate levels of anxiety.
• C. Inadequate social support.
• D. Altered health maintenance.

Correct answer: B

Rationale: The nurse should initiate a referral based on moderate levels of anxiety (B) as the client reports feeling nervous all the time, sleep disturbances, poor appetite, and difficulty solving problems. These symptoms are indicative of significant anxiety levels. The client does not mention symptoms related to altered thought processes (A) or inadequate social support (C). There is insufficient information to suggest altered health maintenance (D) as a reason for referral in this scenario.

2. A teenaged male client is admitted to the postoperative unit following open reduction of a fractured femur which occurred when he fell down the stairs at a party. The nurse notices needle marks on the client's arms and plans to observe for narcotic withdrawal. Early signs of narcotic withdrawal include which assessment findings?

• A. Vomiting, seizures, and loss of consciousness.
• B. Depression, fatigue, and dizziness.
• C. Hypotension, shallow respirations, and dilated pupils.
• D. Agitation, sweating, and abdominal cramps.

Correct answer: D

Rationale: Agitation, sweating, and abdominal cramps are early signs of narcotic withdrawal. Vomiting, seizures, and loss of consciousness (Option A) are more indicative of severe withdrawal or overdose symptoms. Depression, fatigue, and dizziness (Option B) are not typically early signs of narcotic withdrawal. Hypotension, shallow respirations, and dilated pupils (Option C) are more associated with opioid overdose rather than withdrawal. Monitoring for agitation, sweating, and abdominal cramps is crucial for managing narcotic withdrawal symptoms effectively.

3. A newly admitted client describes her mission in life as one of saving her son by eliminating the 'provocative sluts' of the world. There are several attractive young women on the unit. What should the LPN/LVN do first?

• A. Ask the client for her definition of 'provocative sluts'
• B. Ask the young female clients on the unit to dress less provocatively
• C. Ask the client to discuss her concerns in the next group session
• D. Ask the client to inform the staff if she has negative thoughts about other clients

Correct answer: D

Rationale: The correct action for the LPN/LVN to take first is to ask the client to inform the staff if she has negative thoughts about other clients. This approach is crucial as it helps in monitoring the client's thoughts and behaviors, potentially preventing any harmful actions towards others on the unit. Asking for the client's definition of 'provocative sluts' (Choice A) may not address the immediate concern of monitoring the client's harmful thoughts. Asking the young female clients to dress less provocatively (Choice B) is inappropriate and victim-blaming. Asking the client to discuss her concerns in the next group session (Choice C) may not be effective in addressing the potential harm the client's thoughts could pose to others on the unit.

4. A client who has just been sexually assaulted is calm and quiet. The nurse analyzes this behavior as indicating which defense mechanism?

• A. Denial
• B. Projection
• C. Rationalization
• D. Intellectualization

Correct answer: A

Rationale: The correct answer is A: Denial. In this situation, the client's calm and quiet demeanor after a traumatic event like sexual assault may indicate denial, a defense mechanism where the individual refuses to acknowledge the reality of the distressing event. Choice B, Projection, involves attributing one's thoughts or feelings to others. Choice C, Rationalization, is a defense mechanism where logical reasoning is used to justify behaviors or feelings. Choice D, Intellectualization, is a defense mechanism where excessive reasoning or logic is used to avoid uncomfortable emotions.

5. A client diagnosed with undifferentiated schizophrenia is being discharged on aripiprazole (Abilify) 5 mg every night. When developing the teaching plan about the most common adverse effects, which of the following should the nurse include? Select one that does not apply.

• A. Headaches that will subside in a few weeks
• B. Transient mild anxiety
• C. Insomnia
• D. Torticollis

Correct answer: D

Rationale: The correct answer is D: Torticollis. Common side effects of aripiprazole include headaches, mild anxiety, and insomnia. These side effects are manageable during treatment. Torticollis is not a common adverse effect associated with aripiprazole and is more commonly seen with other medications or conditions. Therefore, the nurse should not include torticollis in the teaching plan about the most common adverse effects of aripiprazole.

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