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. The LPN/LVN is assessing a client's intelligence. Which factor should the nurse remember during this part of the mental status exam?

• A. Acute psychiatric illnesses impair intelligence.
• B. Intelligence is influenced by social and cultural factors.
• C. Poor concentration skills suggest limited intelligence.
• D. The inability to think abstractly indicates limited intelligence.

Correct answer: B

Rationale: The correct answer is B because intelligence is influenced by social and cultural factors. Social and cultural beliefs can impact how intelligence is perceived and expressed. Choice A is incorrect because acute psychiatric illnesses can affect cognitive functioning but not necessarily intelligence. Choice C is incorrect because poor concentration skills do not always correlate with limited intelligence. Choice D is incorrect because the inability to think abstractly is just one aspect of intelligence and does not solely indicate limited intelligence.

3. A client with bipolar disorder is being treated with lithium. The nurse should monitor the client for which early sign of lithium toxicity?

• A. Diarrhea
• B. Tremors
• C. Polyuria
• D. Blurred vision

Correct answer: A

Rationale: Corrected Rationale: Diarrhea is an early sign of lithium toxicity. When a client being treated with lithium presents with diarrhea, it can indicate the beginning of lithium toxicity. Monitoring for this symptom is crucial as it can progress to more severe toxicity if not addressed promptly. Tremors (choice B) are more commonly associated with the therapeutic effects of lithium rather than toxicity. Polyuria (choice C) is a common side effect of lithium, but it is not typically an early sign of toxicity. Blurred vision (choice D) is not a common early sign of lithium toxicity. Therefore, option A is the correct answer.

4. A client with depression reports difficulty sleeping. What is the most appropriate nursing intervention?

• A. Encourage the client to take short naps during the day.
• B. Suggest the client drink a warm beverage before bedtime.
• C. Recommend the client exercise immediately before bedtime.
• D. Advise the client to take a sleep aid nightly.

Correct answer: B

Rationale: The most appropriate nursing intervention for a client with depression reporting difficulty sleeping is to suggest the client drink a warm beverage before bedtime. A warm beverage can promote relaxation and help establish a bedtime routine, which may aid in improving sleep quality. Encouraging short naps during the day (Choice A) may disrupt the client's nighttime sleep pattern. Recommending exercise immediately before bedtime (Choice C) can have a stimulating effect, making it harder for the client to fall asleep. Advising the client to take a sleep aid nightly (Choice D) should only be considered after other non-pharmacological interventions have been attempted and in consultation with a healthcare provider due to potential side effects and risks associated with sleep aids.

5. During the manic phase of bipolar disorder, what is the priority nursing intervention for a female client who has not slept for the past 48 hours, is hyperactive, talkative, and engaging in risky behaviors?

• A. Encourage the client to participate in a quiet activity.
• B. Provide a safe environment and limit stimuli.
• C. Administer a sedative to help the client sleep.
• D. Discuss the consequences of her risky behaviors.

Correct answer: B

Rationale: The correct priority nursing intervention for a female client in the manic phase of bipolar disorder, who has not slept for 48 hours, is hyperactive, talkative, and engaging in risky behaviors, is to provide a safe environment and limit stimuli. This approach is crucial to prevent harm to the client and others. Encouraging a quiet activity (Choice A) may not effectively address the need for safety during the manic phase. Administering a sedative (Choice C) should be done under the guidance of a healthcare provider and does not address the immediate safety concerns. Discussing consequences of risky behaviors (Choice D) may not be effective during the manic phase when the client's judgment is impaired.

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