Nursing Elites

1. A client with schizophrenia is experiencing auditory hallucinations. What is the most appropriate nursing intervention?

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

Correct answer: A

Rationale: The most appropriate nursing intervention for a client with schizophrenia experiencing auditory hallucinations is to encourage the client to focus on reality-based activities. This intervention helps redirect their attention away from hallucinations, promoting engagement with the environment. Choice B is incorrect as telling the client that the voices are not real may invalidate their experiences and worsen the therapeutic relationship. Choice C may increase the client's distress by focusing on the hallucinations. Choice D might not be helpful as interacting with others who are not experiencing hallucinations may not address the client's current needs.

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. During discharge planning for a male client with schizophrenia who insists on returning to his apartment despite being informed to move to a boarding home, what is the most important nursing diagnosis?

• A. Ineffective denial related to situational anxiety.
• B. Ineffective coping related to inadequate support.
• C. Social isolation related to difficult interactions.
• D. Self-care deficit related to cognitive impairment.

Correct answer: A

Rationale: The most important nursing diagnosis for discharge planning in this scenario is 'Ineffective denial related to situational anxiety.' The client's insistence on returning to his apartment despite being informed otherwise indicates a form of denial, possibly due to anxiety about the situational change. Focused discharge planning should address this denial and the underlying anxiety to ensure a smooth transition. Choices B, C, and D are not as relevant in this context as the primary issue lies in the client's denial and anxiety regarding the change in living arrangements, rather than coping, social interactions, or self-care deficits.

4. A client with obsessive-compulsive disorder (OCD) repeatedly checks the locks on the doors. What is the best nursing intervention?

• A. Encourage the client to discuss their fears.
• B. Limit the client's time for ritualistic behavior.
• C. Assist the client to complete the ritual faster.
• D. Prevent the client from engaging in the behavior.

Correct answer: A

Rationale: The best nursing intervention when dealing with a client with OCD who repeatedly checks locks is to encourage the client to discuss their fears. This approach can help the client identify underlying anxiety triggers and work towards developing alternative coping mechanisms. Choice B, limiting the client's time for ritualistic behavior, may increase anxiety and worsen symptoms by creating a sense of urgency. Choice C, assisting the client to complete the ritual faster, does not address the underlying issues and may reinforce the behavior. Choice D, preventing the client from engaging in the behavior, can lead to increased anxiety and distress for the client.

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.

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