Nursing Elites

1. 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.

2. A client with a history of bipolar disorder presents to the emergency department with symptoms of mania. What is the priority nursing intervention?

• A. Administer prescribed medication to manage symptoms.
• B. Provide a calm environment with minimal stimulation.
• C. Encourage the client to express feelings and emotions.
• D. Reinforce the need for consistent medication adherence.

Correct answer: A

Rationale: Administering prescribed medication to manage symptoms is the priority intervention for a client with symptoms of mania. During a manic episode, the client may be at risk of harm to self or others due to impulsivity and poor judgment. Medication helps stabilize the client, reduce manic symptoms, and prevent further escalation. Providing a calm environment (choice B) is important but not the priority when the client's safety is at risk. Encouraging expression of feelings (choice C) and reinforcing medication adherence (choice D) are valuable aspects of care but addressing the acute symptoms of mania takes precedence to ensure the client's immediate safety and well-being.

3. A client with bipolar disorder is admitted to the psychiatric unit in a manic state. What is the most therapeutic nursing intervention?

• A. Allow the client to engage in any activity they choose.
• B. Provide a structured environment with reduced stimuli.
• C. Encourage the client to express their thoughts freely.
• D. Place the client in a room with another client for socialization.

Correct answer: B

Rationale: During a manic state, individuals with bipolar disorder may exhibit hyperactivity, impulsivity, and reduced need for sleep. Providing a structured environment with reduced stimuli is the most therapeutic nursing intervention as it can help manage the client's excessive energy and prevent overstimulation. Choice A is incorrect as allowing the client to engage in any activity they choose may exacerbate their symptoms or lead to risky behaviors. Choice C, encouraging the client to express their thoughts freely, may not be appropriate during a manic state as it can further escalate their racing thoughts. Choice D, placing the client in a room with another client for socialization, may not be beneficial during a manic episode as it could increase stimulation and potentially lead to agitation.

4. At the first meeting of a group of older adults at a daycare center for the elderly, the nurse asks one of the members what kinds of things she would like to do with the group. The older woman shrugs her shoulders and says, 'You tell me, you're the leader.' What is the best response for the nurse to make?

• A. 'Yes, I am the leader today. Would you like to be the leader tomorrow?'
• B. 'Yes, I will be leading this group. What would you like to accomplish during this time?'
• C. 'Yes, I have been assigned to be the leader of this group. I will be here for the next six weeks.'
• D. 'Yes, I am the leader. You seem angry about not being the leader yourself.'

Correct answer: B

Rationale: (B) provides information and focuses the group back to defining its function. (A) is manipulative bargaining. (C) does not focus on the group’s purpose. (D) challenges the client’s feelings.

5. The nurse asks a female client with borderline personality disorder, 'How do you feel about your children not coming to visit this weekend?' The client looks out the window and replies, 'I really don't care.' Which response is best for the nurse to provide?

• A. I noticed you were looking out the window when discussing your feelings.
• B. I think you're lying and it bothers you that your children aren't coming.
• C. I think you should discuss your children not coming in the group meeting.
• D. Why do you think your children didn't want to come visit you this weekend?

Correct answer: A

Rationale: Acknowledging the client's non-verbal behavior, such as looking out the window, demonstrates active listening and provides the client with an opportunity to explore their feelings further. Choice B is incorrect as it accuses the client of lying without any evidence, which can damage the therapeutic relationship. Choice C is inappropriate as it dismisses the client's feelings and suggests a group discussion without addressing the client's emotions directly. Choice D is also incorrect as it focuses on the children's actions rather than the client's feelings, missing an opportunity for therapeutic communication.

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