Nursing Elites

1. The client is planning discharge for a male client with schizophrenia. The client insists that he is returning to his apartment, although the healthcare provider informed him that he will be moving to a boarding home. What is the most important nursing diagnosis for discharge planning?

• A. Ineffective denial related to situational anxiety.
• B. Ineffective coping related to inadequate support.
• C. Social isolation related to difficult interactions.
• D. Self-care deficit related to cognitive impairment.

Correct answer: A

Rationale: The best nursing diagnosis is (A) because the client is unable to acknowledge the move to a boarding home. While (B, C, and D) are potential nursing diagnoses, denial is the most critical as it is a defense mechanism preventing the client from addressing his feelings regarding the change in living arrangements.

2. A client with post-traumatic stress disorder (PTSD) reports having frequent nightmares. What is the nurse's best response?

• A. Nightmares are common with PTSD and should decrease over time.
• B. Try to avoid thinking about the trauma before going to bed.
• C. Let's discuss some relaxation techniques you can use before bedtime.
• D. I will ask the healthcare provider to prescribe a sleep aid.

Correct answer: C

Rationale: The best response for the nurse is to discuss relaxation techniques with the client that can help reduce anxiety and stress before bedtime. This approach may potentially decrease the frequency of nightmares by promoting a more calming and peaceful pre-sleep routine. Choice A is incorrect because while nightmares can be common with PTSD, it is not guaranteed that they will decrease over time. Choice B is incorrect as avoiding thinking about the trauma may not address the underlying issue causing the nightmares. Choice D is incorrect as prescribing a sleep aid should be considered as a last resort after trying non-pharmacological interventions.

3. A female victim of sexual assault is being seen in the crisis center. The client states that she still feels 'as though the rape just happened yesterday,' even though it has been a few months since the incident. The appropriate nursing response is which of the following?

• A. You need to try to be realistic. The rape did not just occur.
• B. It will take some time to get over these feelings about your rape.
• C. Tell me more about the incident that causes you to feel like the rape just occurred.
• D. What do you think you can do to alleviate some of your fears about being raped again?

Correct answer: C

Rationale: The correct response is to encourage the client to talk about the event that makes them feel as though the rape just occurred. This approach can help the client process their feelings and experiences, which is crucial in dealing with trauma. Choice A is dismissive and negates the client's feelings, which can be harmful. Choice B, although acknowledging the time needed to heal, does not actively address the client's current feelings. Choice D shifts the focus to future fears rather than addressing the client's current emotional state.

4. A client is admitted to the hospital with a diagnosis of anorexia nervosa. What is the most important intervention for the LPN/LVN to implement during the first 24 hours of hospitalization?

• A. Encourage the client to eat small, frequent meals.
• B. Monitor the client's vital signs and weight.
• C. Establish a trusting relationship with the client.
• D. Provide emotional support to the client.

Correct answer: B

Rationale: The correct answer is to monitor the client's vital signs and weight. This intervention is crucial in assessing the severity of the client's condition and planning appropriate care. Vital signs and weight monitoring help in evaluating the client's physiological status and identifying any immediate concerns related to anorexia nervosa. Choices A, C, and D are important aspects of care for a client with anorexia nervosa; however, during the initial 24 hours of hospitalization, monitoring vital signs and weight takes precedence as it provides essential data for the client's ongoing management and treatment.

5. A client states that she hears God's voice telling her that she has sinned and needs to punish herself. Which response by the LPN/LVN is most important?

• A. How do you think you will be punished?
• B. Please tell staff when you think you need to punish yourself.
• C. What exactly do you think you have done to be punished?
• D. Let's talk about your strengths

Correct answer: B

Rationale: The most important response by the LPN/LVN is to encourage the client to communicate with staff when they feel the need to punish themselves. This approach can help assess the risk of self-harm and enable appropriate intervention. Choice A focuses more on the method of punishment rather than encouraging help-seeking behavior. Choice C seeks specific details about the perceived wrongdoing rather than addressing the immediate concern of self-punishment. Choice D, discussing strengths, does not directly address the client's current distress and potential self-harm risk.

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