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. A 52-year-old male client in the intensive care unit who has been oriented suddenly becomes disoriented and fearful. Assessment of vital signs and other physical parameters reveal no significant change, and the nurse formulates the diagnosis, 'Confusion related to ICU psychosis.' Which intervention would be best to implement?

• A. Move all machines away from the client's immediate area.
• B. Attempt to allay the client's fears by explaining the etiology of his condition.
• C. Cluster care so that brief periods of rest can be scheduled during the day.
• D. Extend visitation times for family and friends.

Correct answer: C

Rationale: In critical care environments, stressors can lead to isolation and confusion. Providing the client with scheduled rest periods (C) can help alleviate these symptoms. Moving all machines away (A) is impractical as they are often essential. Explaining the condition (B) may not be effective during acute confusion. Extending visitation times (D) can be overwhelming for the client in the ICU.

3. 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.

4. An adolescent who attempted suicide with a drug overdose arrives in the emergency department with an empty 30-tablet bottle of acetaminophen (Tylenol). Which action should the nurse implement?

• A. Administer acetylcysteine (Mucomyst).
• B. Monitor cardiac rhythm for flat T waves.
• C. Check both serum AST and ALT levels.
• D. Prepare to administer Syrup of Ipecac.

Correct answer: A

Rationale: The correct action for the nurse to implement is to administer acetylcysteine (Mucomyst). Acetylcysteine is the antidote for acetaminophen overdose and should be administered promptly to prevent liver damage. Monitoring cardiac rhythm for flat T waves (Choice B) is not specific to acetaminophen overdose and is more related to cardiac conditions. Checking serum AST and ALT levels (Choice C) may be done later but is not the initial priority in this situation. Similarly, preparing to administer Syrup of Ipecac (Choice D) is not recommended anymore in cases of overdose as it can cause more harm.

5. The LPN/LVN is assessing a client's intelligence. Which factor should the nurse remember during this part of the mental status exam?

• A. Acute psychiatric illnesses impair intelligence.
• B. Intelligence is influenced by social and cultural factors.
• C. Poor concentration skills suggest limited intelligence.
• D. The inability to think abstractly indicates limited intelligence.

Correct answer: B

Rationale: The correct answer is B because intelligence is influenced by social and cultural factors. Social and cultural beliefs can impact how intelligence is perceived and expressed. Choice A is incorrect because acute psychiatric illnesses can affect cognitive functioning but not necessarily intelligence. Choice C is incorrect because poor concentration skills do not always correlate with limited intelligence. Choice D is incorrect because the inability to think abstractly is just one aspect of intelligence and does not solely indicate limited intelligence.

Similar Questions