Nursing Elites

1. A client with bipolar disorder is admitted to the psychiatric unit in a manic state. What is the most therapeutic nursing intervention?

• A. Allow the client to engage in any activity they choose.
• B. Provide a structured environment with reduced stimuli.
• C. Encourage the client to express their thoughts freely.
• D. Place the client in a room with another client for socialization.

Correct answer: B

Rationale: During a manic state, individuals with bipolar disorder may exhibit hyperactivity, impulsivity, and reduced need for sleep. Providing a structured environment with reduced stimuli is the most therapeutic nursing intervention as it can help manage the client's excessive energy and prevent overstimulation. Choice A is incorrect as allowing the client to engage in any activity they choose may exacerbate their symptoms or lead to risky behaviors. Choice C, encouraging the client to express their thoughts freely, may not be appropriate during a manic state as it can further escalate their racing thoughts. Choice D, placing the client in a room with another client for socialization, may not be beneficial during a manic episode as it could increase stimulation and potentially lead to agitation.

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. A client with depression is started on a selective serotonin reuptake inhibitor (SSRI). What should the LPN/LVN include in the teaching plan?

• A. Take the medication with food to avoid nausea.
• B. You may start feeling better within 1 to 2 weeks.
• C. The medication may take 4 to 6 weeks to become fully effective.
• D. You may experience side effects such as dry mouth or dizziness.

Correct answer: C

Rationale: Teaching the client that the medication may take 4 to 6 weeks to become fully effective is crucial as it helps set realistic expectations. While choice A is important to reduce nausea, it is not the most critical information to provide initially. Choice B is incorrect as improvement usually occurs after several weeks of treatment, not within 1 to 2 weeks. Choice D is also relevant, but informing about the full effectiveness of the medication is more important for long-term adherence.

4. A client with a history of alcohol dependence tells the nurse that he has been sober for three months but has recently started drinking again. What should the nurse do next?

• A. Ask the client why he started drinking again.
• B. Provide information about support groups for sobriety.
• C. Discuss the consequences of drinking on his health.
• D. Encourage the client to express his feelings about relapse.

Correct answer: D

Rationale: Encouraging the client to express his feelings about relapse is the most appropriate action for the nurse to take in this situation. This approach allows the nurse to address the underlying emotions and factors contributing to the relapse. Choice A, asking the client why he started drinking again, may come across as judgmental and might not be as effective in exploring the client's emotions. Choice B, providing information about support groups, is important but should come after addressing the client's current emotional state. Choice C, discussing the consequences of drinking, may be necessary at some point, but initially, the focus should be on the client's feelings and emotions surrounding the relapse.

5. What is the most appropriate nursing intervention for a client with obsessive-compulsive disorder (OCD) who is constantly washing her hands?

• A. Allow the client to continue washing her hands.
• B. Set limits on the time spent washing her hands.
• C. Encourage the client to wash her hands less frequently.
• D. Assist the client in finding alternative ways to reduce anxiety.

Correct answer: D

Rationale: Assisting the client in finding alternative ways to reduce anxiety is the most appropriate intervention for a client with OCD who is constantly washing her hands. This approach helps address the underlying cause of the compulsive behavior by focusing on reducing anxiety rather than reinforcing the behavior. Allowing the client to continue washing her hands (choice A) would not address the root of the issue and may perpetuate the behavior. Setting limits on the time spent washing hands (choice B) may cause distress to the client and does not address the core problem. Encouraging the client to wash her hands less frequently (choice C) does not provide effective coping strategies for managing anxiety associated with OCD.

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