Nursing Elites

1. When planning care for a client with anorexia nervosa, which goal should be prioritized?

• A. The client will establish normal eating patterns.
• B. The client will verbalize feelings about food and weight.
• C. The client will gain a minimum of 2 pounds per week.
• D. The client will achieve normal electrolyte balance.

Correct answer: D

Rationale: The correct answer is D because achieving normal electrolyte balance is critical in clients with anorexia nervosa. Electrolyte imbalances can lead to serious, life-threatening complications such as cardiac arrhythmias and organ failure. While establishing normal eating patterns (choice A) and verbalizing feelings about food and weight (choice B) are important aspects of treatment, addressing electrolyte balance takes precedence due to the immediate risks associated with imbalances. Additionally, setting a weight gain goal of 2 pounds per week (choice C) may not be appropriate initially as rapid refeeding can also lead to electrolyte imbalances and other complications.

2. What is the most therapeutic nursing response for a client with borderline personality disorder who engages in self-mutilating behavior?

• A. Encourage the client to stop hurting themselves.
• B. Discuss what the client was feeling before self-harming.
• C. Inform the client that the behavior will be reported to their doctor.
• D. Ask the client why they hurt themselves.

Correct answer: B

Rationale: The most therapeutic nursing response for a client with borderline personality disorder engaging in self-mutilating behavior is to discuss what the client was feeling before self-harming. This approach helps in exploring the underlying triggers and emotions that lead to self-harm. Option A is directive and may come across as judgmental rather than empathetic. Option C can lead to feelings of betrayal and breach of trust. Option D is a closed-ended question that may not facilitate open communication or exploration of emotions.

3. Within several days of hospitalization, a client is repeatedly washing the top of the same table. Which initial intervention is best for the nurse to implement to help the client cope with anxiety related to this behavior?

• A. Administer a prescribed PRN antianxiety medication.
• B. Assist the client in identifying stimuli that precipitate the ritualistic activity.
• C. Allow time for the ritualistic behavior, then redirect the client to other activities.
• D. Teach the client relaxation and thought-stopping techniques.

Correct answer: C

Rationale: Initially, the nurse should allow time for the ritualistic behavior (C) to prevent anxiety. Administering an antianxiety medication (A) may help reduce the client's anxiety temporarily but will not address the underlying issue of ineffective coping mechanisms leading to the behavior. While assisting the client in identifying triggers (B) is important for long-term therapy, the immediate focus should be on managing the behavior. Teaching relaxation and thought-stopping techniques (D) is beneficial but might be more effective once the client is more stable and receptive to learning new coping strategies.

4. A nurse is caring for a client with major depressive disorder who is withdrawn and refuses to participate in group activities. What is the best nursing intervention?

• A. Encourage the client to attend at least one group session.
• B. Respect the client's wish to remain isolated.
• C. Arrange for individual therapy sessions.
• D. Offer the client a list of activities to choose from.

Correct answer: A

Rationale: Encouraging the client to attend at least one group session is the best nursing intervention in this scenario. By gently encouraging participation, the nurse can help the client start to engage with others, which may gradually improve their mood and social interaction. Choice B, respecting the client's wish to remain isolated, may further exacerbate the client's withdrawal and depression by reinforcing avoidance behavior. Choice C, arranging for individual therapy sessions, can be beneficial but may not address the specific need for social interaction. Choice D, offering a list of activities to choose from, does not directly address the client's difficulty in participating in group activities and may not provide the necessary support in overcoming social withdrawal.

5. On admission assessment, the nurse is obtaining subjective data about a client's sexual and reproductive status. The client states, 'I don't want to discuss this; it's private and personal.' Which response by the LVN/LPN is the most therapeutic?

• A. I'd hate being asked these sorts of questions too, but it's a necessary part of providing you with the best care.
• B. This is difficult for you to speak about, but I need this information from you in order to perform a complete assessment.
• C. I am a professional registered nurse, and, as such, I'll have you know that all your information is certainly kept confidential.
• D. I know that some of these questions are difficult for you, but, as a professional nurse, I am obligated to respect your confidentiality.

Correct answer: D

Rationale: The correct response is D. Respecting the client's privacy while acknowledging the difficulty of the situation and explaining the professional obligation to maintain confidentiality is the most therapeutic approach. This response shows empathy, understanding, and a commitment to confidentiality, which can help build trust and encourage the client to open up. Choices A, B, and C do not effectively address the client's concerns or emphasize the importance of confidentiality in a sensitive manner, making them less therapeutic responses in this situation.

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