Nursing Elites

1. Physical examination of a 6-year-old reveals several bite marks in various locations on his body. X-ray examination reveals healed fractures of the ribs. The mother tells the nurse that her child is always having accidents. Which initial response by the nurse is most appropriate?

• A. I need to inform the healthcare provider about your child's tendency to be accident-prone.
• B. Tell me more specifically about your child's accidents.
• C. I must report these injuries to the authorities because they do not seem accidental.
• D. Boys this age always seem to require more supervision and can be quite accident-prone.

Correct answer: B

Rationale: (B) seeks more information in a non-threatening manner to gather additional details about the child's accidents. This response allows the nurse to explore the situation further without making assumptions. (A) fails to address the concerning findings and instead focuses on informing the healthcare provider. (C) jumps to conclusions without gathering more information, potentially causing unnecessary distress to the family. (D) dismisses the seriousness of the situation by attributing the injuries to common accidents for boys, missing the opportunity to delve deeper into the issue.

2. The client is planning discharge for a male client with schizophrenia. The client insists that he is returning to his apartment, although the healthcare provider informed him that he will be moving to a boarding home. What is the most important nursing diagnosis for discharge planning?

• A. Ineffective denial related to situational anxiety.
• B. Ineffective coping related to inadequate support.
• C. Social isolation related to difficult interactions.
• D. Self-care deficit related to cognitive impairment.

Correct answer: A

Rationale: The best nursing diagnosis is (A) because the client is unable to acknowledge the move to a boarding home. While (B, C, and D) are potential nursing diagnoses, denial is the most critical as it is a defense mechanism preventing the client from addressing his feelings regarding the change in living arrangements.

3. When caring for a client with borderline personality disorder in a psychiatric unit, what is the most therapeutic nursing intervention?

• A. Set clear and consistent boundaries for the client.
• B. Allow the client to vent their feelings without interruption.
• C. Encourage the client to participate in group therapy.
• D. Provide the client with frequent reassurance and support.

Correct answer: A

Rationale: Setting clear and consistent boundaries is the most therapeutic nursing intervention when caring for a client with borderline personality disorder. This approach provides structure, promotes predictability, and helps prevent manipulative behaviors. By establishing boundaries, the nurse can maintain a safe therapeutic relationship with the client. Allowing the client to vent their feelings without interruption (Choice B) may not always be beneficial, as it could reinforce maladaptive behaviors. Encouraging participation in group therapy (Choice C) can be helpful but setting boundaries is more critical for individualized care. Providing the client with frequent reassurance and support (Choice D) may not address the underlying issues and can contribute to dependency rather than fostering independence and coping skills.

4. On admission assessment, the nurse is obtaining subjective data about a client's sexual and reproductive status. The client states, 'I don't want to discuss this; it's private and personal.' Which response by the LVN/LPN is the most therapeutic?

• A. I'd hate being asked these sorts of questions too, but it's a necessary part of providing you with the best care.
• B. This is difficult for you to speak about, but I need this information from you in order to perform a complete assessment.
• C. I am a professional registered nurse, and, as such, I'll have you know that all your information is certainly kept confidential.
• D. I know that some of these questions are difficult for you, but, as a professional nurse, I am obligated to respect your confidentiality.

Correct answer: D

Rationale: The correct response is D. Respecting the client's privacy while acknowledging the difficulty of the situation and explaining the professional obligation to maintain confidentiality is the most therapeutic approach. This response shows empathy, understanding, and a commitment to confidentiality, which can help build trust and encourage the client to open up. Choices A, B, and C do not effectively address the client's concerns or emphasize the importance of confidentiality in a sensitive manner, making them less therapeutic responses in this situation.

5. The nurse is planning care for a 32-year-old male client diagnosed with HIV infection who has a history of chronic depression. Recently, the client's viral load has begun to increase rather than decrease despite his adherence to the HIV drug regimen. What should the nurse do first while taking the client's history upon admission to the hospital?

• A. Determine if the client attends a support group weekly.
• B. Hold all antidepressant medications until further notice.
• C. Ask the client if he takes St. John's Wort routinely.
• D. Have the client describe any recent changes in mood.

Correct answer: C

Rationale: The nurse's top priority upon admission is to determine if the client has been taking St. John's Wort, an herbal preparation often used for depression. St. John's Wort can interact adversely with medications used to treat HIV infection, potentially explaining the rise in the viral load (C). Asking about attending support groups (A) or recent changes in mood (D) may provide valuable information about the client's depression but is not as critical as determining St. John's Wort use. Holding antidepressant medications (B) without assessing for potential interactions can be harmful to the client.

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