Nursing Elites

1. An older female adult who lives in a nursing home is loudly demanding that the nurse call her son who has been deceased for five years. Which intervention should the nurse implement?

• A. Assist the client in making the phone call.
• B. Remind the client about her son's passing.
• C. Escort the client to a private area.
• D. Direct the client to a new activity.

Correct answer: D

Rationale: In this situation, the most appropriate intervention is to direct the client to a new activity. This approach can help redirect the client's attention, distract her from the distressing request, and engage her in a more positive interaction. Choice A could exacerbate the client's distress by attempting to make the impossible call, and reminding the client about her son's passing (Choice B) may increase her emotional distress. Escorting the client to a private area (Choice C) does not address the underlying issue and may not effectively manage the situation.

2. The parents of a nuclear family attending a support group for parents of adolescents are being assessed by the nurse. According to Erikson, these parents who are adapting to middle adulthood should exhibit which characteristic?

• A. Loss of independence.
• B. Increased self-understanding.
• C. Isolation from society.
• D. Development of intimate relationships.

Correct answer: B

Rationale: The correct answer is B: Increased self-understanding. According to Erikson's psychosocial development theory, middle adulthood is characterized by generativity, self-reflection, understanding, and acceptance. Middle-aged adults focus on guiding the next generation and finding meaning in their lives. Choices A and C are incorrect because loss of independence and isolation from society are maladaptive behaviors in middle adulthood. While developing and maintaining intimate relationships is important throughout life, the initial development of intimate relationships typically occurs during young adulthood, not middle adulthood.

3. A client who has been diagnosed with borderline personality disorder is exhibiting manipulative behavior. What is the most important intervention for the LPN/LVN to implement?

• A. Set clear, consistent limits on manipulative behavior.
• B. Ignore the manipulative behavior to avoid reinforcing it.
• C. Remind the client that manipulative behavior is unacceptable.
• D. Explain the consequences of manipulative behavior to the client.

Correct answer: A

Rationale: Setting clear, consistent limits on manipulative behavior is the most important intervention for a client diagnosed with borderline personality disorder. This approach helps establish boundaries, maintain a therapeutic environment, and provide structure for the client. Choice B is incorrect because ignoring manipulative behavior can lead to its reinforcement. Choice C, while important, may not be as effective as directly setting limits. Choice D focuses on consequences rather than immediate intervention, making it less effective than setting clear limits.

4. The nurse asks a female client with borderline personality disorder, 'How do you feel about your children not coming to visit this weekend?' The client looks out the window and replies, 'I really don't care.' Which response is best for the nurse to provide?

• A. I noticed you were looking out the window when discussing your feelings.
• B. I think you're lying and it bothers you that your children aren't coming.
• C. I think you should discuss your children not coming in the group meeting.
• D. Why do you think your children didn't want to come visit you this weekend?

Correct answer: A

Rationale: Acknowledging the client's non-verbal behavior, such as looking out the window, demonstrates active listening and provides the client with an opportunity to explore their feelings further. Choice B is incorrect as it accuses the client of lying without any evidence, which can damage the therapeutic relationship. Choice C is inappropriate as it dismisses the client's feelings and suggests a group discussion without addressing the client's emotions directly. Choice D is also incorrect as it focuses on the children's actions rather than the client's feelings, missing an opportunity for therapeutic communication.

5. A 65-year-old female client complains to the nurse that recently she has been hearing voices. What question should the nurse ask this client first?

• A. Do you have problems with hallucinations?
• B. Are you ever alone when you hear the voices?
• C. Has anyone in your family had hearing problems?
• D. Do you see things that others cannot see?

Correct answer: B

Rationale: The nurse should first ask if the client is ever alone when she hears the voices. This question helps differentiate between potential auditory hallucinations and other causes like hearing loss. Choice A is not the best first question as it assumes the client is experiencing hallucinations without exploring other possibilities. Choice C is irrelevant to the immediate concern of hearing voices. Choice D pertains to visual hallucinations which are not described in the client's complaint of hearing voices.

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