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 female client with post-traumatic stress disorder (PTSD) has been experiencing flashbacks. Which intervention should the nurse implement to help the client?

• A. Encourage the client to talk about the trauma.
• B. Advise the client to avoid triggers that cause flashbacks.
• C. Help the client stay grounded in the present moment.
• D. Refer the client to group therapy for PTSD.

Correct answer: C

Rationale: The correct intervention for a client with PTSD experiencing flashbacks is to help them stay grounded in the present moment. This technique can reduce the intensity of flashbacks and provide a sense of safety. Encouraging the client to talk about the trauma (Choice A) may exacerbate the symptoms and should be done cautiously under professional guidance. Advising the client to avoid triggers (Choice B) is important, but solely relying on avoidance may not address the underlying issues. Referring the client to group therapy (Choice D) can be beneficial, but in the immediate context of managing flashbacks, grounding techniques are more appropriate.

3. Select the nursing interventions for a hospitalized client with mania who is exhibiting manipulative behavior. Select one intervention that does not apply.

• A. Communicate expected behaviors to the client
• B. Ensure that the client knows that he or she is not in charge of the nursing unit
• C. Assist the client in identifying ways of setting limits on personal behaviors
• D. Follow through about the consequences of behavior in a non-punitive manner

Correct answer: B

Rationale: The correct answer is B. Ensuring that the client knows they are not in charge of the nursing unit is not a helpful nursing intervention for managing manipulative behavior in a client with mania. Communicating expected behaviors, assisting with limit-setting, and following through on consequences in a non-punitive manner are more appropriate interventions to address manipulative behavior.

4. A client with schizophrenia is being treated with haloperidol (Haldol). The client reports feeling restless and unable to sit still. What should the nurse do first?

• A. Instruct the client to take deep breaths and relax.
• B. Assess the client for signs of akathisia.
• C. Encourage the client to engage in physical activity.
• D. Administer a PRN dose of lorazepam (Ativan).

Correct answer: B

Rationale: Restlessness and inability to sit still are signs of akathisia, an extrapyramidal side effect of antipsychotic medications. The nurse should first assess the client for signs of akathisia by observing their movements and behavior. Assessing for akathisia is crucial to differentiate it from other conditions and to intervene appropriately. Instructing the client to relax or engage in physical activity may not address the underlying issue of akathisia. Administering lorazepam should not be the first action as it may mask the symptoms of akathisia temporarily without addressing the root cause.

5. A client with schizophrenia is being treated with haloperidol (Haldol) and begins to exhibit symptoms of tardive dyskinesia. What is the nurse's priority action?

• A. Continue the medication and monitor for worsening symptoms.
• B. Administer the next dose of haloperidol with food.
• C. Report the symptoms to the healthcare provider immediately.
• D. Educate the client about the side effects of haloperidol.

Correct answer: C

Rationale: The correct answer is to report the symptoms to the healthcare provider immediately. Tardive dyskinesia is a serious side effect of antipsychotic medications, including haloperidol. Prompt reporting is crucial to evaluate the need for medication adjustment or change in treatment. Continuing the medication without intervention (choice A) can worsen the symptoms. Administering the next dose (choice B) is not appropriate when tardive dyskinesia is suspected. Educating the client (choice D) is important but not the priority when dealing with acute symptoms of tardive dyskinesia.

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