Nursing Elites

1. The LPN/LVN should include which interventions in the plan of care for a severely depressed client with neurovegetative symptoms? (select one that does not apply.)

• A. Permit rest periods as needed.
• B. Speaking slowly and simply.
• C. Place the client on suicide precautions.
• D. Limit and discourage food and fluid intake.

Correct answer: D

Rationale: For a severely depressed client with neurovegetative symptoms, the care plan should include rest, simple communication, suicide precautions, monitoring intake, and encouraging mild exercise. Limiting and discouraging food and fluid intake is not appropriate as proper nutrition and hydration are essential for overall well-being. This choice could lead to further complications and is not recommended in the care of a depressed client.

2. A teenaged client, a heroin addict, is admitted to the unit for detoxification. What intervention is most important for the nurse to initiate during the first 24 hours after admission?

• A. Assign the client to a teen support group.
• B. Assess intake and output.
• C. Monitor for wheezing and apnea.
• D. Limit visitors to family members only.

Correct answer: B

Rationale: Assessing intake and output is crucial during the first 24 hours after admission for detoxification. This helps the nurse monitor the client's hydration status and kidney function as the body goes through withdrawal from heroin. Option A is incorrect because joining a support group is beneficial but may not be the priority in the initial phase of detoxification. Option C, monitoring for wheezing and apnea, is important but not the most critical intervention during the first 24 hours. Option D, limiting visitors to family members only, is not directly related to the immediate needs of assessing intake and output.

3. The nurse is caring for a client who received the first-time electroconvulsive therapy (ECT) a half hour ago. Which action should the nurse implement first?

• A. Offer oral fluids.
• B. Monitor vital signs.
• C. Evaluate ECT effectiveness.
• D. Encourage group participation.

Correct answer: B

Rationale: After a client receives electroconvulsive therapy (ECT), the nurse's priority should be to monitor vital signs. This is important to ensure the client's physical stability and detect any immediate complications post-procedure. Offering oral fluids, evaluating ECT effectiveness, and encouraging group participation are all important aspects of care but monitoring vital signs takes precedence in the immediate post-ECT period.

4. A young adult male client is admitted to the psychiatric unit because of a recent suicide attempt. His wife filed for divorce six months ago, he lost his job three months ago, and his best friend moved to another city two weeks ago. Which intervention should the nurse include in the client's plan of care?

• A. Encourage the client to interact with individuals who are recovering from depression.
• B. Allow the client time alone to sort out his feelings.
• C. Avoid discussing topics that upset the client.
• D. Encourage activities that allow the client to exert control over his environment.

Correct answer: D

Rationale: Encouraging activities that allow the client to exert control over his environment can be therapeutic in cases of depression and stress. It helps improve the client's sense of agency, which is essential for promoting feelings of empowerment and self-worth. Choice A could potentially be overwhelming for the client, especially considering his recent suicide attempt and ongoing stressors. Choice B might not be the most beneficial intervention as isolation could further exacerbate feelings of loneliness and hopelessness. Choice C, avoiding discussing upsetting subjects, may prevent the client from addressing and processing his emotions, hindering therapeutic progress.

5. A 22-year-old male client is admitted to the emergency center following a suicide attempt. His records reveal that this is his third suicide attempt in the past two years. He is conscious, but does not respond to verbal commands for treatment. Which assessment finding should prompt the nurse to prepare the client for gastric lavage?

• A. He ingested the drug 3 hours prior to admission to the emergency center.
• B. The family reports that he took an entire bottle of acetaminophen (Tylenol).
• C. He is unresponsive to instructions and is unable to cooperate with emetic therapy.
• D. Those with repeated suicide attempts desire punishment to relieve their guilt.

Correct answer: C

Rationale: The correct answer is C because the client's unresponsiveness and inability to cooperate with emetic therapy indicate the need for gastric lavage. Gastric lavage is a procedure used to remove toxic substances from the stomach in cases where the patient is unresponsive or unable to cooperate. Choice A is incorrect as the time of ingestion alone does not indicate the need for gastric lavage. Choice B, although indicating a significant overdose, does not directly necessitate gastric lavage. Choice D is incorrect as it provides information about the possible psychological motivation for repeated suicide attempts, but it is not directly related to the immediate need for gastric lavage in this scenario.

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