Nursing Elites

1. 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 to instructions and inability to cooperate with emetic therapy would make it challenging to implement such therapy effectively. In such cases, gastric lavage may be necessary to remove the ingested substance. Choices A and B are important considerations in treatment planning but do not directly indicate the need for gastric lavage. Choice D is incorrect as medical treatments should never be used as punitive measures but rather for therapeutic purposes.

2. The wife of a client diagnosed with paranoid schizophrenia visits 2 days after her husband's admission and states to the nurse, 'Why isn't he eating? He's still talking about his food being poisoned.' Which of the following appraisals by the LPN/LVN is most accurate?

• A. The wife's inquiry is reasonable.
• B. Education about her husband's medication is needed.
• C. Her expectations of her husband are realistic.
• D. An increase in the client's medication is needed.

Correct answer: B

Rationale: The correct answer is B. The wife needs education about her husband's medication to understand how it affects his perceptions, including paranoid thoughts about food. Choice A is incorrect because the wife's inquiry reflects her lack of understanding of the situation rather than being reasonable. Choice C is incorrect as the husband's condition requires specialized care beyond what the wife might consider realistic. Choice D is incorrect as increasing medication should not be the immediate response; education and reassurance are key in this situation.

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. 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.

5. A client who has recently been diagnosed with schizophrenia tells the LPN/LVN, 'I hear voices telling me to hurt myself.' What is the most appropriate nursing action?

• A. Encourage the client to ignore the voices.
• B. Tell the client that the voices will go away with medication.
• C. Monitor the client for signs of self-harm.
• D. Refer the client for a psychiatric evaluation.

Correct answer: D

Rationale: The correct answer is to refer the client for a psychiatric evaluation. The client's statement indicating hearing voices telling them to hurt themselves is a serious concern and suggests a risk for self-harm. Referring the client for a psychiatric evaluation is crucial for further assessment and intervention by mental health professionals. Choice A is incorrect because ignoring the voices may not address the client's safety. Choice B is incorrect as it oversimplifies the situation and does not address the immediate risk. Choice C is not as comprehensive as referring for a psychiatric evaluation, which is necessary in this situation.

Similar Questions