over a period of several weeks one male participant of a socialization group at a community day care center for the elderly monopolizes most of the gr
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Nursing Elites

HESI LPN

HESI Mental Health

1. Over a period of several weeks, one male participant of a socialization group at a community day care center for the elderly monopolizes most of the group's time and interrupts others when they are talking. What is the best action for the nurse to take in this situation?

Correct answer: C

Rationale: Allowing the group to handle the situation is the best action as it promotes group dynamics and empowerment, especially since the group is in the working phase. Talking to the participant individually (A) might be seen as manipulative. Reminding the participant (B) can come across as dictatorial and may not address the underlying issue. Asking the participant to join another group (D) does not address the problem at hand and avoids the opportunity for growth and conflict resolution within the current group.

2. In the described scenario, a manic client threatens a nurse with physical violence after being told they cannot have a stripper perform. What is the most appropriate action for the LPN/LVN to take?

Correct answer: C

Rationale: In this situation, where the manic client becomes verbally abusive and threatens physical violence, the most appropriate action for the LPN/LVN is to escort the client to her room with assistance. This action helps ensure the safety of both the client and the nurse, while also providing a controlled environment that can help de-escalate the situation. Choices A and B do not address the immediate safety concerns presented by the client's behavior. Choice D, revoking smoking privileges, is not directly related to the client's current behavior and does not address the threat of violence.

3. The LPN/LVN is caring for a client with post-traumatic stress disorder (PTSD). Which intervention is most appropriate for the nurse to implement?

Correct answer: B

Rationale: Assisting the client in developing coping strategies is an appropriate intervention for managing PTSD. This approach helps the client build resilience and learn how to effectively cope with symptoms. Choice A, encouraging the client to talk about the traumatic event, may not be appropriate as it can potentially re-traumatize the client. Referring the client to a PTSD support group, as in choice C, can be beneficial but may not be the most immediate intervention. Administering medications, as in choice D, is important in some cases, but focusing on coping strategies should be prioritized as a holistic approach to managing PTSD.

4. The nurse is admitting a male client who takes lithium carbonate (Eskalith) twice a day. Which information should the nurse report to the healthcare provider immediately?

Correct answer: D

Rationale: Nausea and vomiting should be reported immediately because they could indicate lithium toxicity, which requires urgent medical attention to prevent more severe effects. Short-term memory loss, depressed affect, and weight gain are common side effects of lithium but do not require immediate medical attention compared to symptoms of toxicity like nausea and vomiting.

5. A male client approaches the nurse with an angry expression on his face and raises his voice, saying, 'My roommate is the most selfish, self-centered, angry person I have ever met. If he loses his temper one more time with me, I am going to punch him out!' The nurse recognizes that the client is using which defense mechanism?

Correct answer: B

Rationale: The correct answer is B: Projection. In this scenario, the client is projecting his own feelings of anger and selfishness onto his roommate. Projection is a defense mechanism where individuals attribute their own unacceptable thoughts, feelings, and motives to another person. Choices A, C, and D are incorrect. Denial is refusing to acknowledge an aspect of reality or experience. Rationalization is providing logical-sounding reasons to justify unacceptable behaviors or feelings. Splitting is seeing individuals as all good or all bad, with no middle ground.

Similar Questions

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A client with major depressive disorder is started on fluoxetine (Prozac). What should the nurse include in the client's discharge teaching?
A client with schizophrenia receiving haloperidol (Haldol) has a stiff, mask-like facial expression and difficulty speaking. What is the nurse's priority action?
A client on the psychiatric unit appears to imitate a certain nurse on the unit. The client seeks out this particular nurse and imitates her mannerisms. Which defense mechanism does the nurse recognize in this client?
Which action should the nurse implement during the termination phase of the nurse-client relationship?

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