Nursing Elites

1. A client with schizophrenia receiving haloperidol (Haldol) has a stiff, mask-like facial expression and difficulty speaking. What is the nurse's priority action?

• A. Administer a PRN dose of lorazepam (Ativan).
• B. Encourage the client to perform facial exercises.
• C. Notify the healthcare provider of possible extrapyramidal symptoms (EPS).
• D. Document the findings and continue to monitor the client.

Correct answer: C

Rationale: The correct answer is to notify the healthcare provider of possible extrapyramidal symptoms (EPS). The symptoms described, such as a stiff, mask-like facial expression and difficulty speaking, are indicative of EPS, which can be a serious side effect of haloperidol. It is crucial to involve the healthcare provider immediately to address these symptoms. Administering a PRN dose of lorazepam (Choice A) is not the priority in this situation, as it does not address the underlying cause of EPS. Encouraging the client to perform facial exercises (Choice B) is not appropriate and may not effectively manage EPS. Documenting the findings and continuing to monitor the client (Choice D) is important but not the priority when potential EPS is present; immediate action by notifying the healthcare provider is essential.

2. A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to a nurse, 'I'm finally cured.' The LPN/LVN interprets this behavior as a cue to modify the treatment plan by:

• A. Suggesting a reduction of medication
• B. Allowing increased 'in-room' activities
• C. Increasing the level of suicide precautions
• D. Allowing the client off-unit privileges as needed

Correct answer: C

Rationale: A sudden improvement in mood and declaring being cured can be warning signs of a decision to attempt suicide. Therefore, the appropriate action would be to increase the level of suicide precautions to ensure the safety of the client. This can involve closer monitoring and restriction of items that could be harmful. Choices A, B, and D are incorrect as they do not address the potential risk of suicide that may be present with the sudden change in behavior.

3. A client states that she hears God's voice telling her that she has sinned and needs to punish herself. Which response by the LPN/LVN is most important?

• A. How do you think you will be punished?
• B. Please tell staff when you think you need to punish yourself.
• C. What exactly do you think you have done to be punished?
• D. Let's talk about your strengths

Correct answer: B

Rationale: The most important response by the LPN/LVN is to encourage the client to communicate with staff when they feel the need to punish themselves. This approach can help assess the risk of self-harm and enable appropriate intervention. Choice A focuses more on the method of punishment rather than encouraging help-seeking behavior. Choice C seeks specific details about the perceived wrongdoing rather than addressing the immediate concern of self-punishment. Choice D, discussing strengths, does not directly address the client's current distress and potential self-harm risk.

4. 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.

5. A male client with schizophrenia tells the nurse that the FBI is monitoring his phone calls. What is the nurse's best response?

• A. Let's talk about your feelings of being monitored.
• B. There is no evidence that the FBI is monitoring your calls.
• C. Why do you think the FBI is interested in your phone calls?
• D. I can assure you that your phone calls are not being monitored.

Correct answer: A

Rationale: The correct response is to choose A: 'Let's talk about your feelings of being monitored.' This response shows empathy and encourages the client to express his feelings. Engaging the client in a discussion about his feelings can help address underlying fears without directly challenging the delusion. Choice B is incorrect because directly denying the delusion may lead to increased distrust or agitation in the client. Choice C may come across as confrontational, which can exacerbate the client's paranoia. Choice D offers a false sense of assurance and does not address the client's concerns effectively.

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