Nursing Elites

1. During the admission assessment, a female client requests that her husband be allowed to stay in the room. While interviewing the client, the nurse notes a discrepancy between the client's verbal and nonverbal communication. What action should the nurse take?

• A. Pay close attention and document the nonverbal messages
• B. Ask the client's husband to interpret the discrepancy
• C. Ignore the nonverbal behavior and focus on the client's verbal messages
• D. Integrate the verbal and nonverbal messages and interpret them as one

Correct answer: A

Rationale: Noting both verbal and nonverbal cues is crucial to fully understand the client's condition and any potential underlying issues. Verbal communication may not always align with nonverbal cues, which can provide valuable insights into the client's emotional state and concerns. By paying close attention to and documenting the nonverbal messages, the nurse can gather a more comprehensive understanding of the client's situation. Asking the client's husband to interpret the discrepancy may not be appropriate as it could lead to misinterpretation or breach of confidentiality. Ignoring the nonverbal behavior could result in missing essential cues affecting the overall assessment. Integrating both verbal and nonverbal messages helps in forming a holistic view of the client's needs and concerns, enabling better care delivery.

2. The LPN/LVN should include which interventions in the plan of care for a severely depressed client with neurovegetative symptoms? (select one that does not apply.)

• A. Permit rest periods as needed.
• B. Speaking slowly and simply.
• C. Place the client on suicide precautions.
• D. Limit and discourage food and fluid intake.

Correct answer: D

Rationale: For a severely depressed client with neurovegetative symptoms, the care plan should include rest, simple communication, suicide precautions, monitoring intake, and encouraging mild exercise. Limiting and discouraging food and fluid intake is not appropriate as proper nutrition and hydration are essential for overall well-being. This choice could lead to further complications and is not recommended in the care of a depressed client.

3. What information should the nurse include in the client's teaching about starting a selective serotonin reuptake inhibitor (SSRI) for major depressive disorder?

• A. It may take several weeks for the medication to take effect.
• B. You can stop taking the medication once you feel better.
• C. Avoid foods high in tyramine while on this medication.
• D. You should expect an immediate improvement in mood.

Correct answer: A

Rationale: The correct answer is A: "It may take several weeks for the medication to take effect." SSRIs typically take several weeks to reach their full effect, and it's important to set realistic expectations for the client. Choice B is incorrect because stopping the medication abruptly can lead to withdrawal symptoms and worsening of depression. Choice C is unrelated to SSRI therapy and pertains more to MAOIs. Choice D is incorrect as SSRIs do not provide immediate improvement in mood; rather, they require time to exert their therapeutic effects.

4. A nurse notes that a depressed female client has been more withdrawn and less communicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client?

• A. Engage the client in non-threatening conversations.
• B. Schedule a daily conference with the social worker.
• C. Encourage the client's family to visit more often.
• D. Encourage the client to participate in group activities.

Correct answer: D

Rationale: The correct answer is to encourage the client to participate in group activities. Group activities can help improve social interaction and potentially reduce feelings of isolation in depressed clients. Choice A, engaging the client in non-threatening conversations, may be helpful but may not address the underlying need for social interaction that group activities can provide. Scheduling a daily conference with the social worker (Choice B) may not directly address the client's need for social engagement. Encouraging the client's family to visit more often (Choice C) is important for support but may not provide the same level of social interaction as group activities.

5. A female client with bulimia nervosa is admitted to the hospital. Which intervention should the nurse include in the plan of care?

• A. Allow the client to eat meals alone to reduce stress.
• B. Observe the client for 30 minutes after meals.
• C. Provide the client with a high-calorie diet.
• D. Encourage the client to weigh herself daily.

Correct answer: B

Rationale: The correct intervention for a client with bulimia nervosa is to observe the client for 30 minutes after meals. This helps prevent purging behaviors, such as vomiting or using laxatives, which are common in bulimia nervosa. Choice A is incorrect because eating meals alone may enable the client to engage in purging behaviors without being observed. Choice C is incorrect as a high-calorie diet may exacerbate the client's concerns about weight gain. Choice D is incorrect because encouraging daily weigh-ins can reinforce obsessive thoughts about weight and body image.

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