Nursing Elites

1. A client is responding to auditory hallucinations and shakes a fist at a nurse and says, 'Back off, witch!' The nurse follows the client into the day room. What action should the nurse implement?

• A. Sit down in a chair near the client.
• B. Position self within an arm's length of the client.
• C. Ensure that there is physical space between the nurse and client.
• D. Move to a position that allows the client to be closest to the room's door.

Correct answer: C

Rationale: In situations where a client is responding to auditory hallucinations and displaying aggressive behavior, it is crucial for the nurse to ensure physical space between themselves and the client. This action can help de-escalate the situation and prevent any potential harm to both the nurse and the client. Sitting down near the client (Choice A) may escalate the situation by invading the client's personal space. Positioning oneself within an arm's length of the client (Choice B) may increase the risk of physical confrontation. Moving closer to the room's door (Choice D) may not be appropriate as it can block the client's exit route and escalate the situation further. Therefore, ensuring physical space between the nurse and the client (Choice C) is the most appropriate action to promote safety and prevent escalation.

2. A client with bipolar disorder is being treated with lithium. The nurse should monitor the client for which early sign of lithium toxicity?

• A. Diarrhea
• B. Tremors
• C. Polyuria
• D. Blurred vision

Correct answer: A

Rationale: Corrected Rationale: Diarrhea is an early sign of lithium toxicity. When a client being treated with lithium presents with diarrhea, it can indicate the beginning of lithium toxicity. Monitoring for this symptom is crucial as it can progress to more severe toxicity if not addressed promptly. Tremors (choice B) are more commonly associated with the therapeutic effects of lithium rather than toxicity. Polyuria (choice C) is a common side effect of lithium, but it is not typically an early sign of toxicity. Blurred vision (choice D) is not a common early sign of lithium toxicity. Therefore, option A is the correct answer.

3. How should the RN respond to the mother?

• A. Ask the mother if she has ever thought about harming herself or her child.
• B. Reassure the mother that her child will achieve some growth and development milestones.
• C. Determine if the mother has other children who do not have developmental disabilities.
• D. Encourage the mother to write her thoughts and feelings in a journal.

Correct answer: A

Rationale: The correct response is to ask the mother if she has ever thought about harming herself or her child. This is crucial to assess for suicidal or homicidal thoughts, ensuring the safety of both the mother and the child. Reassuring the mother about achieving some milestones may not address her immediate emotional distress. Inquiring about other children's developmental status is not the priority when safety concerns are present. While journaling can be therapeutic, in this situation, addressing safety takes precedence.

4. A client with schizophrenia is experiencing distressful thoughts secondary to paranoia. Which intervention(s) should the LPN/LVN include in the plan of care? Select one intervention that does not apply.

• A. Avoid laughing when near the client
• B. Whisper when communicating near the client
• C. Increase socialization of the client among peers
• D. Have the client sign a written release of information form

Correct answer: B

Rationale: The correct intervention for a client with schizophrenia experiencing distressful thoughts secondary to paranoia is to avoid laughing when near the client. This is important as laughter can be misinterpreted and exacerbate the client's paranoia. Whispering when communicating near the client is not an appropriate intervention as it may lead the client to think secretive or negative information is being shared about them, further fueling their paranoia. Increasing socialization among peers can help provide support and reduce feelings of isolation, while having the client sign a written release of information form is not directly related to managing paranoia and distressful thoughts.

5. A middle-aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and low motivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning?

• A. Provide education on methods to enhance sleep.
• B. Teach the client to develop a plan for daily structured activities.
• C. Suggest that the client develop a list of pleasurable activities.
• D. Encourage the client to exercise.

Correct answer: B

Rationale: Teaching the client to develop a plan for daily structured activities is the most effective intervention in this case. Creating a routine can help improve motivation and provide a sense of accomplishment, aiding in the recovery process. Option A, providing education on methods to enhance sleep, may address hypersomnia but does not directly target psychomotor retardation and low motivation. Option C, suggesting the client develop a list of pleasurable activities, may not address the need for structure and routine. Option D, encouraging the client to exercise, is beneficial but may not be as effective as creating a structured daily plan to address the client's specific symptoms.

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