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. 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.

3. A nurse working in a psychiatric unit is assessing a client who appears to be responding to internal stimuli. The client is laughing and talking to himself. What is the nurse's best initial response?

• A. Approach the client and ask if he is hearing voices.
• B. Ignore the behavior as it is common in psychiatric settings.
• C. Encourage the client to express his thoughts verbally.
• D. Observe the client's behavior from a distance.

Correct answer: A

Rationale: Approaching the client and asking if he is hearing voices is the best initial response by the nurse. This action can help assess the situation and determine if the client is experiencing hallucinations that may require immediate intervention. Choice B is incorrect because ignoring the behavior could lead to missing important signs of distress or potential risks. Choice C may not address the immediate concern of assessing for hallucinations. Choice D is also not ideal as observing from a distance may not provide the necessary information for immediate assessment and intervention.

4. A client with schizophrenia is being treated with clozapine (Clozaril). What laboratory test is most important for the nurse to monitor?

• A. Liver function tests
• B. Kidney function tests
• C. White blood cell count
• D. Blood glucose levels

Correct answer: C

Rationale: The correct answer is C: White blood cell count. Clozapine can lead to agranulocytosis, a severe drop in white blood cells, which can be life-threatening. Monitoring the white blood cell count is crucial to detect this condition early. Choices A, B, and D are incorrect because while liver and kidney function tests are important in monitoring other aspects of health, the most critical concern with clozapine therapy is the risk of agranulocytosis, making monitoring white blood cell count the priority.

5. A male client is admitted to the mental health unit because he was feeling depressed about the loss of his wife and job. The client has a history of alcohol dependency and admits that he was drinking alcohol 12 hours ago. Vital signs are: temperature, 100 F, pulse 100, and BP 142/100. The nurse plans to give the client lorazepam (Ativan) based on which priority nursing diagnosis?

• A. Risk for injury related to suicidal ideation.
• B. Risk for injury related to alcohol detoxification.
• C. Knowledge deficit related to ineffective coping.
• D. Health-seeking behaviors related to personal crisis.

Correct answer: B

Rationale: The most important nursing diagnosis is related to alcohol detoxification (B) because the client has elevated vital signs, a sign of alcohol detoxification. Giving lorazepam (Ativan) to address the elevated vital signs due to alcohol withdrawal is a priority. Addressing the risk for injury related to suicidal ideation (A) should come after stabilizing the client's physiological state. Both (C) and (D) can be addressed once immediate safety needs are met, but the priority is managing the alcohol detoxification to prevent potential complications.

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