Nursing Elites

1. An emergency department nurse is caring for an adult client who is a victim of family violence. Which priority instruction would be included in the discharge instructions?

• A. Information regarding shelters
• B. Instructions regarding calling the police
• C. Instructions regarding self-defense classes
• D. Explaining the importance of leaving the violent situation

Correct answer: A

Rationale: The correct answer is A: Information regarding shelters. Providing information about shelters is crucial in cases of family violence as it ensures the client has a safe place to go after discharge, prioritizing their immediate safety. Option B, instructions regarding calling the police, may be necessary but ensuring a safe place to stay is more immediate. Option C, instructions regarding self-defense classes, may not be appropriate as the priority is to ensure the client's safety rather than teaching self-defense. Option D, explaining the importance of leaving the violent situation, is relevant but providing information on immediate shelter options is the priority.

2. On admission assessment, the nurse is obtaining subjective data about a client's sexual and reproductive status. The client states, 'I don't want to discuss this; it's private and personal.' Which response by the LVN/LPN is the most therapeutic?

• A. I'd hate being asked these sorts of questions too, but it's a necessary part of providing you with the best care.
• B. This is difficult for you to speak about, but I need this information from you in order to perform a complete assessment.
• C. I am a professional registered nurse, and, as such, I'll have you know that all your information is certainly kept confidential.
• D. I know that some of these questions are difficult for you, but, as a professional nurse, I am obligated to respect your confidentiality.

Correct answer: D

Rationale: The correct response is D. Respecting the client's privacy while acknowledging the difficulty of the situation and explaining the professional obligation to maintain confidentiality is the most therapeutic approach. This response shows empathy, understanding, and a commitment to confidentiality, which can help build trust and encourage the client to open up. Choices A, B, and C do not effectively address the client's concerns or emphasize the importance of confidentiality in a sensitive manner, making them less therapeutic responses in this situation.

3. A 40-year-old male client diagnosed with schizophrenia and alcohol dependence has not had any visitors or phone calls since admission. He reports he has no family that cares about him and was living on the streets prior to this admission. According to Erikson's theory of psychosocial development, which stage is the client in at this time?

• A. Isolation.
• B. Stagnation.
• C. Despair.
• D. Role confusion.

Correct answer: B

Rationale: The client is in Erikson's 'Generativity vs. Stagnation' stage (age 24 to 45). This stage involves maintaining intimate relationships and moving toward developing a family, which the client seems to be struggling with due to lack of visitors and family support. Choices (A), (C), and (D) are incorrect. Isolation typically occurs in young adulthood (age 18 to 25), Despair in maturity (age 45 to death), and Role confusion in adolescence (age 12 to 20). These stages reflect challenges individuals face if they do not successfully navigate their psychosocial developmental tasks.

4. What is the most important nursing intervention during the first 48 hours for a client with anorexia nervosa admitted to the hospital?

• A. Providing high-calorie, high-protein meals.
• B. Monitoring vital signs and electrolytes.
• C. Encouraging the client to talk about feelings.
• D. Observing for signs of purging.

Correct answer: B

Rationale: The most important nursing intervention during the first 48 hours for a client with anorexia nervosa is monitoring vital signs and electrolytes (B) to assess for life-threatening complications. This helps in early detection of any physiological imbalances that could lead to serious consequences. Providing high-calorie, high-protein meals (A) is important for nutritional rehabilitation but comes after ensuring the client's physical stability. Encouraging the client to talk about feelings (C) and observing for signs of purging (D) are relevant aspects of care but are not as critical as monitoring vital signs and electrolytes in the initial phase of treatment.

5. A client with a diagnosis of major depressive disorder is prescribed fluoxetine (Prozac). What is the most important side effect for the LPN/LVN to monitor?

• A. Weight gain.
• B. Sexual dysfunction.
• C. Nausea.
• D. Constipation.

Correct answer: B

Rationale: The correct answer is B: Sexual dysfunction. When monitoring a client taking fluoxetine (Prozac), the LPN/LVN should prioritize observing for sexual dysfunction. This side effect is crucial to monitor as it can significantly impact the client's quality of life and may affect their adherence to the medication. Weight gain (choice A) is a possible side effect of fluoxetine but is not as critical as sexual dysfunction in terms of monitoring. Nausea (choice C) and constipation (choice D) are common side effects of fluoxetine, but they are generally less concerning compared to the impact of sexual dysfunction on the client's well-being and treatment compliance.

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