Nursing Elites

1. The LPN/LVN is caring for a client who is experiencing alcohol withdrawal. Which intervention should the nurse implement first?

• A. Administer a PRN dose of lorazepam (Ativan).
• B. Monitor the client's vital signs.
• C. Place the client on seizure precautions.
• D. Encourage the client to express feelings about withdrawal.

Correct answer: B

Rationale: When caring for a client experiencing alcohol withdrawal, the first intervention the nurse should implement is to monitor the client's vital signs. Vital sign monitoring is crucial to assess for any potential complications such as hypertension, tachycardia, fever, or other signs of autonomic hyperactivity. Administering medication like lorazepam (Ativan) would come after assessing the vital signs to determine the need for pharmacological intervention. Placing the client on seizure precautions is important, but assessing vital signs takes precedence to ensure immediate safety. Encouraging the client to express feelings about withdrawal is a supportive intervention but does not address the immediate physiological risk associated with alcohol withdrawal.

2. A male client with schizophrenia tells the nurse that the voices he hears are saying, 'You must kill yourself.' To assist the client in coping with these thoughts, which response is best for the nurse to provide?

• A. Tell yourself that the voices are unreasonable.'
• B. Exercise when you hear the voices.'
• C. Talk to someone when you hear the voices.'
• D. The voices aren't real, so ignore them.'

Correct answer: A

Rationale: The nurse should teach the client to use self-talk to disprove the voices. Although exercising may be helpful, the client's concrete thinking may make it difficult to understand this suggestion. Clients with schizophrenia have difficulty initiating interaction with others. Auditory hallucinations are often relentless, so it is difficult to ignore them.

3. 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.

4. 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.

5. An elderly female client with advanced dementia is admitted to the hospital with a fractured hip. The client repeatedly tells the staff, 'Take me home. I want my Mommy.' Which response is best for the nurse to provide?

• A. Orient the client to the time, place, and person.
• B. Tell the client that the nurse is there and will help her.
• C. Remind the client that her mother is no longer living.
• D. Explain the seriousness of her injury and need for hospitalization.

Correct answer: B

Rationale: Those with dementia often refer to home or parents when seeking security and comfort. The nurse should use the techniques of 'offering self' and 'talking to the feelings' to provide reassurance (B). Clients with advanced dementia have permanent physiological changes in the brain (plaques and tangles) that prevent them from comprehending and retaining new information, so choices A, C, and D are likely to be of little use to this client and do not address the emotional needs expressed by the client. Option B acknowledges the client's feelings, offers support, and provides reassurance, which can help comfort the client during this distressing time.

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