Nursing Elites

1. During initial assessment of the teenager, what information is most important for the nurse to obtain from the parents?

• A. If he has seemed depressed recently.
• B. If a drug overdose has ever occurred before.
• C. If he might have taken any other drugs.
• D. If he has a desire to quit taking drugs.

Correct answer: C

Rationale: The correct answer is C. It's crucial to determine if the teenager might have taken other substances besides the pain pills mentioned by the mother. This information is vital for effective treatment because knowing the full scope of substances involved helps in managing potential interactions, side effects, and the overall condition of the patient. Options A, B, and D are not as critical in the immediate assessment compared to knowing if the teenager has ingested any other drugs.

2. When developing a plan of care for a client in the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing diagnosis has the highest priority?

• A. Risk for injury.
• B. Ineffective coping mechanisms.
• C. Alteration in comfort.
• D. Ineffective breathing patterns.

Correct answer: D

Rationale: When a client aspirates a caustic material, the priority nursing diagnosis should focus on addressing physiological concerns, particularly related to breathing patterns. Aspiration of caustic material can lead to airway compromise, respiratory distress, and potential lung damage. Therefore, monitoring and addressing ineffective breathing patterns are crucial for ensuring the client's immediate safety and well-being. Choices A, B, and C are important considerations in psychiatric care but are secondary to the critical physiological issue of ineffective breathing patterns in this scenario.

3. A 65-year-old female client complains to the nurse that recently she has been hearing voices. What question should the nurse ask this client first?

• A. Do you have problems with hallucinations?
• B. Are you ever alone when you hear the voices?
• C. Has anyone in your family had hearing problems?
• D. Do you see things that others cannot see?

Correct answer: B

Rationale: The nurse should first ask if the client is ever alone when she hears the voices. This question helps differentiate between potential auditory hallucinations and other causes like hearing loss. Choice A is not the best first question as it assumes the client is experiencing hallucinations without exploring other possibilities. Choice C is irrelevant to the immediate concern of hearing voices. Choice D pertains to visual hallucinations which are not described in the client's complaint of hearing voices.

4. 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.

5. A client who has been diagnosed with borderline personality disorder is exhibiting manipulative behavior. What is the most important intervention for the LPN/LVN to implement?

• A. Set clear, consistent limits on manipulative behavior.
• B. Ignore the manipulative behavior to avoid reinforcing it.
• C. Remind the client that manipulative behavior is unacceptable.
• D. Explain the consequences of manipulative behavior to the client.

Correct answer: A

Rationale: Setting clear, consistent limits on manipulative behavior is the most important intervention for a client diagnosed with borderline personality disorder. This approach helps establish boundaries, maintain a therapeutic environment, and provide structure for the client. Choice B is incorrect because ignoring manipulative behavior can lead to its reinforcement. Choice C, while important, may not be as effective as directly setting limits. Choice D focuses on consequences rather than immediate intervention, making it less effective than setting clear limits.

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