Nursing Elites

1. At the first meeting of a group of older adults at a daycare center for the elderly, the nurse asks one of the members what kinds of things she would like to do with the group. The older woman shrugs her shoulders and says, 'You tell me, you're the leader.' What is the best response for the nurse to make?

• A. 'Yes, I am the leader today. Would you like to be the leader tomorrow?'
• B. 'Yes, I will be leading this group. What would you like to accomplish during this time?'
• C. 'Yes, I have been assigned to be the leader of this group. I will be here for the next six weeks.'
• D. 'Yes, I am the leader. You seem angry about not being the leader yourself.'

Correct answer: B

Rationale: (B) provides information and focuses the group back to defining its function. (A) is manipulative bargaining. (C) does not focus on the group’s purpose. (D) challenges the client’s feelings.

2. 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.

3. The LPN/LVN is assessing a client who is taking an antipsychotic medication. Which of the following symptoms is uniquely indicative of neuroleptic malignant syndrome (NMS) and requires immediate attention?

• A. Very high temperature
• B. Muscular rigidity
• C. Tremors
• D. Altered consciousness

Correct answer: A

Rationale: A very high temperature is a hallmark symptom of Neuroleptic Malignant Syndrome (NMS), which is a rare but potentially life-threatening side effect of antipsychotic medications. This symptom is uniquely indicative of NMS and requires immediate medical attention. Muscular rigidity, tremors, and altered consciousness can be seen in other conditions but are not as specifically linked to NMS as a very high temperature.

4. A client with depression is started on a selective serotonin reuptake inhibitor (SSRI). The client asks, 'How long will it take for this medication to work?' What is the best response by the nurse?

• A. It may take 2 to 4 weeks before you start feeling better.
• B. You should start feeling better within a few days.
• C. The medication works immediately to improve your mood.
• D. It may take up to 8 weeks for the medication to take full effect.

Correct answer: D

Rationale: Explaining that it may take up to 8 weeks for the medication to take full effect provides the client with a realistic expectation. SSRI medications typically require time to build up in the body and exert their therapeutic effects. Choice A is incorrect as it underestimates the time frame required for the medication to work. Choice B is incorrect as SSRIs do not produce immediate effects. Choice C is incorrect as it falsely states that the medication works immediately, which is not true for SSRIs.

5. A client is admitted to the hospital with a diagnosis of anorexia nervosa. What is the most important intervention for the LPN/LVN to implement during the first 24 hours of hospitalization?

• A. Encourage the client to eat small, frequent meals.
• B. Monitor the client's vital signs and weight.
• C. Establish a trusting relationship with the client.
• D. Provide emotional support to the client.

Correct answer: B

Rationale: The correct answer is to monitor the client's vital signs and weight. This intervention is crucial in assessing the severity of the client's condition and planning appropriate care. Vital signs and weight monitoring help in evaluating the client's physiological status and identifying any immediate concerns related to anorexia nervosa. Choices A, C, and D are important aspects of care for a client with anorexia nervosa; however, during the initial 24 hours of hospitalization, monitoring vital signs and weight takes precedence as it provides essential data for the client's ongoing management and treatment.

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