Nursing Elites

1. A client is admitted to the psychiatric unit with a diagnosis of major depressive disorder. The LPN/LVN notes that the client has not bathed or dressed in clean clothes for several days. What is the most appropriate intervention for the nurse to implement?

• A. Encourage the client to take a shower.
• B. Assist the client with activities of daily living.
• C. Provide the client with clean clothes to change into.
• D. Explain the importance of personal hygiene to the client.

Correct answer: B

Rationale: The correct answer is to assist the client with activities of daily living. This intervention is the most appropriate as it directly addresses the client's immediate needs by providing assistance with personal hygiene and dressing. It promotes self-care and ensures the client's well-being. Encouraging the client to take a shower (Choice A) may not be effective if the client is unable to do so independently due to their condition. Providing clean clothes (Choice C) is important but does not address the client's need for assistance with personal care. Explaining the importance of personal hygiene (Choice D) may not be as effective as providing direct assistance in this situation.

2. A LPN/LVN is preparing to care for a dying client, and several family members are at the client's bedside. Select the therapeutic techniques that the nurse would use when communicating with the family. Select one that does not apply.

• A. Discourage reminiscing
• B. Make decisions for the family
• C. Encourage expression of feelings, concerns, and fears
• D. Explain everything that is happening to all family members

Correct answer: B

Rationale: Encouraging the expression of feelings, concerns, and fears is a therapeutic technique that helps the family cope with the situation and express their emotions. This approach fosters trust and emotional release. Making decisions for the family is not appropriate because it takes away their autonomy and control during a difficult time. Discouraging reminiscing may hinder the family's coping mechanisms by discouraging them from sharing memories and finding comfort in the past. Explaining everything that is happening to all family members promotes transparency and understanding, which can help reduce anxiety and fear.

3. On admission to a residential care facility, an elderly female client tells the nurse that she enjoys cooking, quilting, and watching television. Twenty-four hours after admission, the nurse notes that the client is withdrawn and isolated. It is best for the nurse to encourage this client to become involved in which activity?

• A. Clean the unit kitchen cabinets.
• B. Participate in a group quilting project.
• C. Watch television in the activity room.
• D. Bake a cake for a resident's birthday.

Correct answer: B

Rationale: Peer interaction in a group activity (B) such as participating in a group quilting project will help to prevent social isolation and withdrawal. This will provide the elderly client with an opportunity to engage with others, share experiences, and feel a sense of belonging. Choices (A, C, and D) are activities that can be accomplished alone, without peer interaction, which may not effectively address the client's feelings of withdrawal and isolation.

4. A client on the psychiatric unit appears to imitate a certain nurse on the unit. The client seeks out this particular nurse and imitates the nurse's mannerisms. The nurse knows that the client is using which defense mechanism?

• A. Sublimation.
• B. Identification.
• C. Introjection.
• D. Repression.

Correct answer: B

Rationale: The correct answer is (B) Identification. In this scenario, the client is imitating the nurse's mannerisms, which is a form of identification, a defense mechanism where an individual adopts the characteristics or behaviors of someone they admire or view as powerful. (A) Sublimation involves channeling unacceptable impulses into socially acceptable actions, not imitation. (C) Introjection is the internalization of external qualities or attributes, not imitation. (D) Repression is the unconscious exclusion of painful thoughts or memories from awareness, which is not demonstrated in this case.

5. In observing a client who is pacing, agitated, and presenting aggressive gestures, with rapid speech pattern and belligerent affect, what is the immediate priority of care for the nurse?

• A. Provide safety for the client and other clients on the unit
• B. Provide the clients on the unit with a sense of comfort and safety
• C. Assist the staff in caring for the client in a controlled environment
• D. Offer the client a less stimulated area to calm down and gain control

Correct answer: A

Rationale: In a situation where a client is displaying aggression and agitation, the immediate priority of care for the nurse is to ensure safety for the client and others on the unit. Providing a safe environment and implementing calming measures take precedence over other interventions. Option A is the correct choice as it addresses the crucial need for safety in a potentially volatile situation. Options B, C, and D, although important, do not address the primary concern of ensuring safety for all individuals involved.

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