Nursing Elites

1. A client sought counseling after trying to rescue a neighbor involved in a house fire. Despite the client's efforts, the neighbor died. Which action does the nurse engage in with the client during the working phase of the nurse-client relationship?

• A. Exploring the client's ability to function
• B. Exploring the client's potential for self-harm
• C. Inquiring about the client's perception of appraisal of the neighbor's death
• D. Inquiring about and examining the client's feelings that may block adaptive coping

Correct answer: D

Rationale: During the working phase of the nurse-client relationship, it is crucial for the nurse to inquire about and examine the client's feelings that may hinder adaptive coping. This helps the client process the traumatic event, explore their emotional responses, and identify any barriers to moving forward effectively. Exploring the client's ability to function (Choice A) may be more relevant in the assessment phase, while exploring the client's potential for self-harm (Choice B) is important but may not be the primary focus at this stage. Inquiring about the client's perception of the neighbor's death (Choice C) is valuable, but addressing feelings blocking adaptive coping is essential for therapeutic progress.

2. A client with post-traumatic stress disorder (PTSD) is experiencing a flashback. What is the nurse's priority action?

• A. Encourage the client to talk about the trauma.
• B. Help the client to focus on the present.
• C. Administer prescribed anti-anxiety medication.
• D. Leave the client alone to work through the flashback.

Correct answer: B

Rationale: The priority action is to help the client focus on the present (B), which can reduce the intensity of the flashback. Encouraging discussion of the trauma (A) should be done when the client is not actively experiencing a flashback. While medication (C) may be necessary, it is not the first priority in this situation. Leaving the client alone (D) is not appropriate as they need support to manage the flashback.

3. A client who is being treated with lithium carbonate for bipolar disorder develops diarrhea, vomiting, and drowsiness. What action should the LPN/LVN take?

• A. Notify the healthcare provider immediately and prepare for administration of an antidote.
• B. Notify the healthcare provider of the symptoms prior to the next administration of the drug.
• C. Record the symptoms as normal side effects and continue administration of the prescribed dosage.
• D. Hold the medication and refuse to administer additional amounts of the drug.

Correct answer: B

Rationale: When a client being treated with lithium carbonate for bipolar disorder develops symptoms like diarrhea, vomiting, and drowsiness, it could indicate lithium toxicity. The appropriate action for the LPN/LVN is to notify the healthcare provider immediately of these symptoms before the next administration of the drug. This prompt communication is crucial to ensure that the healthcare provider can assess the situation, adjust the treatment plan if necessary, and prevent potential complications associated with lithium toxicity. Option A is incorrect because administering an antidote should be based on the healthcare provider's assessment. Option C is incorrect as these symptoms are not normal side effects and could indicate a serious issue. Option D is incorrect because refusing to administer the drug without consulting the healthcare provider could delay necessary interventions.

4. A male client with schizophrenia who is taking fluphenazine decanoate (Prolixin decanoate) is being discharged in the morning. A repeat dose of medication is scheduled for 20 days after discharge. The client tells the nurse that he is going on vacation in the Bahamas and will return in 18 days. Which statement by the client indicates a need for health teaching?

• A. "When I return from my tropical island vacation, I will go to the clinic to get my Prolixin injection."
• B. "While I am on vacation and when I return, I will not consume any alcohol-containing food or beverages."
• C. "I will inform the healthcare provider if I develop a sore throat or flu-like symptoms."
• D. "I will maintain my daily intake of benztropine mesylate (Cogentin)."

Correct answer: A

Rationale: Photosensitivity is a side effect of Prolixin, and a vacation in the Bahamas (with its tropical island climate) increases the client's risk of experiencing this side effect. Therefore, the client should be advised to avoid direct sun exposure. Choice A indicates a need for health teaching as the client plans to return from vacation in 18 days, which is earlier than the scheduled dose of Prolixin at 20 days after discharge. Choices B, C, and D demonstrate accurate knowledge. Choice B is important because alcohol can interact with Prolixin. Choice C is relevant as it mentions signs of agranulocytosis, a potential side effect of Prolixin. Choice D is correct as benztropine mesylate is used to prevent extrapyramidal symptoms associated with Prolixin.

5. 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.

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