Nursing Elites

1. An LPN/LVN is reviewing the assessment data of a client admitted to the mental health unit. The nurse notes that the admission nurse documented that the client is experiencing anxiety as a result of a situational crisis. The nurse determines that this type of crisis is caused by:

• A. Witnessing a murder
• B. The death of a loved one
• C. A fire that destroyed the client's home
• D. A recent rape episode experienced by the client

Correct answer: B

Rationale: The correct answer is B: 'The death of a loved one.' A situational crisis, like the death of a loved one, can lead to anxiety due to a significant change or loss in the person's life. Choices A, C, and D involve traumatic events, but a situational crisis typically refers to life events that disrupt an individual's normal pattern of living, such as the death of a loved one.

2. A client with obsessive-compulsive disorder (OCD) is hospitalized for treatment. Which intervention is most important for the LPN/LVN to include in the client's plan of care?

• A. Allow the client to engage in compulsive behaviors as a way to reduce anxiety.
• B. Encourage the client to ignore the compulsive behaviors.
• C. Help the client to understand the purpose of compulsive behaviors.
• D. Work with the client to gradually reduce the frequency of compulsive behaviors.

Correct answer: D

Rationale: The correct intervention for a client with OCD is to work with them to gradually reduce the frequency of compulsive behaviors. This approach helps the client manage their condition effectively without causing undue distress. Allowing the client to engage in compulsive behaviors can reinforce the disorder rather than alleviate it. Encouraging the client to ignore compulsive behaviors does not address the core issue of OCD. While helping the client understand the purpose of compulsive behaviors can be beneficial, actively working to reduce these behaviors is more crucial in the treatment of OCD.

3. A woman brings her 48-year-old husband to the outpatient psychiatric unit and describes his behavior to the admitting nurse. She states that he has been sleepwalking, cannot remember who he is, and exhibits multiple personalities. The nurse knows that these behaviors are often associated with

• A. dissociative disorder.
• B. obsessive-compulsive disorder.
• C. panic disorder.
• D. post-traumatic stress disorder.

Correct answer: A

Rationale: The correct answer is A: dissociative disorder. Sleepwalking, amnesia, and multiple personalities are examples of detaching emotional conflict from one's consciousness, which is the definition of a dissociative disorder. Obsessive-compulsive disorder (B) is characterized by persistent, recurrent intrusive thoughts or urges (obsessions) and compulsions. Panic disorder (C) is characterized by acute attacks of anxiety. Post-traumatic stress disorder (D) involves re-experiencing psychologically distressing events.

4. What assessment is the priority focus for a client with major depression?

• A. Mood and affect.
• B. Suicidal ideation.
• C. Nutritional status.
• D. Fluid and electrolyte balance.

Correct answer: B

Rationale: The correct answer is B: Suicidal ideation. When dealing with a client diagnosed with major depression, assessing for suicidal ideation is of utmost importance. Individuals with major depression have an increased risk of suicide; hence, evaluating their risk for self-harm is crucial. Mood and affect, while important, come secondary to ensuring the safety of the client. Nutritional status and fluid and electrolyte balance are essential components of care but are not the priority when dealing with a client with major depression.

5. When a client with schizophrenia is being discharged on antipsychotic medication, what is the most important instruction the nurse should provide?

• A. Stop the medication if you start feeling better.
• B. Be aware of the potential for weight gain with this medication.
• C. Report any unusual muscle movements immediately.
• D. You can drive as soon as you feel ready.

Correct answer: C

Rationale: The correct answer is to instruct the client to report any unusual muscle movements immediately. These movements may indicate extrapyramidal symptoms (EPS) or tardive dyskinesia, which are serious side effects of antipsychotic medications that require immediate attention. Choice A is incorrect because stopping the medication without medical advice can lead to a relapse of symptoms. Choice B is important but not as critical as monitoring for EPS. Choice D is incorrect because driving readiness is not directly related to antipsychotic medication instructions.

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