Nursing Elites

1. A female client refuses to take an oral hypoglycemic agent because she believes that the drug is being administered as part of an elaborate plan by the Mafia to harm her. Which nursing intervention is most important to include in this client's plan of care?

• A. Reassure the client that no one will harm her while she is in the hospital.
• B. Ask the healthcare provider to give the client the medication.
• C. Explain the importance of taking the diabetic medication.
• D. Reassess the client's mental status for thought processes and content.

Correct answer: D

Rationale: Reassessing the client's mental status is the most important intervention as it is crucial to address the client's delusional thinking. By assessing the client's thought processes and content, the nurse can gain insight into the client's beliefs and tailor interventions accordingly. Reassuring the client that no harm will come to her, asking the healthcare provider to give the medication, or simply explaining the importance of taking the medication may not effectively address the underlying issue of delusional beliefs.

2. A 35-year-old male client on the psychiatric unit of a general hospital believes that someone is trying to poison him. The nurse understands that a client's delusions are most likely related to his

• A. early childhood experiences involving authority issues.
• B. anger about being hospitalized.
• C. low self-esteem.
• D. phobic fear of food.

Correct answer: C

Rationale: Psychotic clients often experience delusions due to difficulties with trust and low self-esteem (C). In this case, the client's belief that someone is trying to poison him is likely a manifestation of his underlying issues with trust and self-worth. Building trust and promoting positive self-esteem are essential in caring for such clients. Choices A, B, and D are incorrect because delusions are not primarily related to early childhood experiences involving authority issues, anger about hospitalization, or phobic fear of food. These factors do not directly contribute to the development of delusions in psychotic clients.

3. A female client with borderline personality disorder expresses fear of being abandoned by the nursing staff. What is the best nursing intervention?

• A. Reassure the client that she will not be abandoned.
• B. Set limits on the client's behavior and enforce them consistently.
• C. Encourage the client to talk about her fears.
• D. Rotate the nursing staff assigned to the client frequently.

Correct answer: B

Rationale: The best nursing intervention for a client with borderline personality disorder expressing fear of abandonment is to set limits on the client's behavior and enforce them consistently. This approach helps establish boundaries and provides a sense of security for the client. Choice A may provide temporary reassurance but does not address the core issue or help the client develop coping strategies. Choice C is important but should be accompanied by setting limits to address the underlying fear of abandonment. Choice D of rotating staff frequently can exacerbate the client's fear of abandonment by reinforcing the idea of being left.

4. Which action should the nurse implement first for a client experiencing alcohol withdrawal?

• A. Apply vest or extremity restraints.
• B. Give an alpha-adrenergic blocker.
• C. Provide a diet high in protein and calories.
• D. Prepare the environment to prevent self-injury.

Correct answer: D

Rationale: The correct action for the nurse to implement first for a client experiencing alcohol withdrawal is to prepare the environment to prevent self-injury. Clients undergoing alcohol withdrawal are at risk of seizures and other symptoms that may lead to self-harm. By ensuring a safe environment, the nurse can mitigate the risk of injury. Applying restraints (Choice A) should only be considered if less restrictive measures fail, as restraints can agitate the client further. Giving an alpha-adrenergic blocker (Choice B) may be part of the treatment plan for alcohol withdrawal but is not the first action to take. Providing a diet high in protein and calories (Choice C) is important for overall health but is not the priority when addressing immediate safety concerns.

5. A client with schizophrenia is being treated with clozapine (Clozaril). What is the most important laboratory test for the LPN/LVN to monitor?

• A. White blood cell count.
• B. Liver function tests.
• C. Blood glucose levels.
• D. Platelet count.

Correct answer: A

Rationale: The most important laboratory test for an LPN/LVN to monitor for a client with schizophrenia being treated with clozapine is the white blood cell count. Clozapine treatment is associated with a risk of agranulocytosis, a severe drop in white blood cells, which can be life-threatening. Monitoring the white blood cell count regularly helps to detect this adverse effect early. Liver function tests (Choice B) are important to monitor with some antipsychotic medications but are not the most crucial for clozapine. Blood glucose levels (Choice C) are more relevant for monitoring in clients on medications like atypical antipsychotics that can cause metabolic side effects. Platelet count (Choice D) is not typically affected by clozapine therapy and is not the most important test to monitor in this case.

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