Nursing Elites

1. A client is admitted to the mental health unit and reports taking extra anti-anxiety medication because, 'I'm so stressed out. I just wanted to go to sleep.' The nurse should plan one-on-one observation of the client based on which statement?

• A. What should I do? Nothing seems to help.
• B. I have been so tired lately and needed to sleep.
• C. I really think that I don't need to be here.
• D. I don't want to talk. Nothing matters anymore.

Correct answer: D

Rationale: The correct answer is D because expressing feelings of hopelessness or nihilism can be indicators of a deeper, possibly dangerous level of depression. Choice A is incorrect as it indicates seeking help, Choice B suggests fatigue, and Choice C implies denial of needing help, none of which directly signify severe depression warranting one-on-one observation.

2. The LPN/LVN is caring for a client with schizophrenia who is experiencing auditory hallucinations. Which intervention is most appropriate?

• A. Encourage the client to focus on reality-based activities.
• B. Ask the client to describe the voices he hears.
• C. Tell the client that the voices are not real.
• D. Encourage the client to interact with others who are not experiencing hallucinations.

Correct answer: B

Rationale: Asking the client to describe the voices he hears is the most appropriate intervention in this situation. It helps the nurse assess the content and severity of the hallucinations, enabling the planning of appropriate interventions. Choice A is not as effective as directly addressing the hallucinations. Choice C may lead to mistrust as the client believes the voices are real. Choice D does not address the client's immediate need related to the hallucinations.

3. Which interventions should the nurse include 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. Allow the client extra time to complete tasks.

Correct answer: C

Rationale: The correct answer is C, 'Place the client on suicide precautions.' When caring for a severely depressed client with neurovegetative symptoms, it is crucial to permit rest periods as needed, speak slowly and simply, and allow the client extra time to complete tasks. These interventions help in promoting the client's comfort and well-being. Placing the client on suicide precautions may not always be necessary and should be based on a thorough assessment of the client's risk of self-harm. Therefore, it is the intervention that does not universally apply to all clients in this situation.

4. A client who has just been sexually assaulted is calm and quiet. The nurse analyzes this behavior as indicating which defense mechanism?

• A. Denial
• B. Projection
• C. Rationalization
• D. Intellectualization

Correct answer: A

Rationale: The correct answer is A: Denial. In this situation, the client's calm and quiet demeanor after a traumatic event like sexual assault may indicate denial, a defense mechanism where the individual refuses to acknowledge the reality of the distressing event. Choice B, Projection, involves attributing one's thoughts or feelings to others. Choice C, Rationalization, is a defense mechanism where logical reasoning is used to justify behaviors or feelings. Choice D, Intellectualization, is a defense mechanism where excessive reasoning or logic is used to avoid uncomfortable emotions.

5. A female client presents to the emergency center with confusion, emotional numbness, and expresses to the nurse a feeling of disbelief that she was raped. The nurse determines the client is in the acute phase of rape-trauma syndrome. What action should the nurse implement first?

• A. Secure samples of vaginal hair combings.
• B. Offer prophylactic antibiotic medication.
• C. Explain the rape protocol to the client.
• D. Implement crisis intervention counseling.

Correct answer: C

Rationale: In cases of rape-trauma syndrome, it is crucial to provide clear information about what to expect during the examination and treatment. This can help the client regain a sense of control and reduce anxiety. Explaining the rape protocol to the client should be the first action to implement. Option A is not the priority at this stage as the immediate focus is on addressing the client's emotional needs and providing support. Option B is not the first action unless medically indicated. Option D, crisis intervention counseling, is important but should come after providing essential information and support to the client.

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