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. The nurse is caring for a client who is experiencing a panic attack. Which intervention should the nurse implement first?

• A. Stay with the client and remain calm.
• B. Encourage the client to express their feelings.
• C. Teach the client deep-breathing exercises.
• D. Administer prescribed anti-anxiety medication.

Correct answer: A

Rationale: The priority intervention is to stay with the client and remain calm (A). This provides immediate support and reassurance. Encouraging the client to express their feelings (B) and teaching deep-breathing exercises (C) are important but should come after ensuring the client's immediate safety and comfort. Administering medication (D) might be necessary, but the nurse should first focus on providing a calming presence to help the client feel safe and supported during the panic attack.

3. The parents of a 14-year-old boy bring their son to the hospital. He is lethargic but responsive. The mother states, 'I think he took some of my pain pills.' During the initial assessment of the teenager, what information is most important for the nurse to obtain from the parents?

• A. If he has seemed depressed recently.
• B. If a drug overdose has ever occurred before.
• C. If he might have taken any other drugs.
• D. If he has a desire to quit taking drugs.

Correct answer: C

Rationale: In a situation where a teenager is brought to the hospital after possibly ingesting pills, the most crucial information for the nurse to obtain from the parents is whether the teenager might have taken any other drugs (C). This knowledge is vital for guiding further treatment, such as administering antagonists, making it the top priority. While information about depression (A) and previous drug overdoses (B) is valuable for treatment planning, it is not as critical as knowing all substances taken. Asking about the teenager's desire to quit taking drugs (D) is not appropriate during the acute management of a drug overdose and does not take precedence over determining what other substances might have been ingested.

4. 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.

5. A client with schizophrenia is experiencing distressful thoughts secondary to paranoia. Which intervention(s) should the LPN/LVN include in the plan of care? Select one intervention that does not apply.

• A. Avoid laughing when near the client
• B. Whisper when communicating near the client
• C. Increase socialization of the client among peers
• D. Have the client sign a written release of information form

Correct answer: B

Rationale: The correct intervention for a client with schizophrenia experiencing distressful thoughts secondary to paranoia is to avoid laughing when near the client. This is important as laughter can be misinterpreted and exacerbate the client's paranoia. Whispering when communicating near the client is not an appropriate intervention as it may lead the client to think secretive or negative information is being shared about them, further fueling their paranoia. Increasing socialization among peers can help provide support and reduce feelings of isolation, while having the client sign a written release of information form is not directly related to managing paranoia and distressful thoughts.

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