Nursing Elites

1. The LPN/LVN calls security and has physical restraints applied when a client who was admitted voluntarily becomes both physically and verbally abusive while demanding to be discharged from the hospital. Which represents the possible legal ramifications for the nurse associated with these interventions? Select one that does not apply.

• A. false imprisonment
• B. Battery
• C. Assault
• D. Slander

Correct answer: D

Rationale: In this scenario, the possible legal ramifications for the nurse could include battery, assault, and false imprisonment. Battery refers to the intentional harmful or offensive touching of another person without consent, which could be perceived when applying physical restraints. Assault is the apprehension of harmful or offensive contact, creating fear in the individual, which can result from the verbal threats and physical actions of the patient. False imprisonment occurs when a person is unlawfully restrained, which may apply if the patient was involuntarily restrained. Slander, on the other hand, is the oral defamation of character, which does not align with the actions described in the scenario, making it the choice that does not apply.

2. An elderly female client with advanced dementia is admitted to the hospital with a fractured hip. The client repeatedly tells the staff, 'Take me home. I want my Mommy.' Which response is best for the LPN/LVN to provide?

• A. Orient the client to the time, place, and person.
• B. Tell the client that the nurse is there and will help her.
• C. Remind the client that her mother is no longer living.
• D. Explain the seriousness of her injury and need for hospitalization.

Correct answer: B

Rationale: The correct answer is to tell the client that the nurse is there and will help her. Providing reassurance and presence is more therapeutic in dealing with a client who has advanced dementia and is expressing a desire to go home and be with her mother. Option A might not be effective as continuously orienting the client may not alleviate her distress. Option C, reminding the client that her mother is no longer living, can be distressing and may not be appropriate in this situation. Option D, explaining the seriousness of the injury and need for hospitalization, is not the best response as it does not address the client's emotional needs at that moment.

3. A client with schizophrenia is being treated with haloperidol (Haldol) and begins to exhibit symptoms of tardive dyskinesia. What is the nurse's priority action?

• A. Continue the medication and monitor for worsening symptoms.
• B. Administer the next dose of haloperidol with food.
• C. Report the symptoms to the healthcare provider immediately.
• D. Educate the client about the side effects of haloperidol.

Correct answer: C

Rationale: The correct answer is to report the symptoms to the healthcare provider immediately. Tardive dyskinesia is a serious side effect of antipsychotic medications, including haloperidol. Prompt reporting is crucial to evaluate the need for medication adjustment or change in treatment. Continuing the medication without intervention (choice A) can worsen the symptoms. Administering the next dose (choice B) is not appropriate when tardive dyskinesia is suspected. Educating the client (choice D) is important but not the priority when dealing with acute symptoms of tardive dyskinesia.

4. A 35-year-old male client on the psychiatric unit of a general hospital believes that someone is trying to poison him. The nurse understands that a client's delusions are most likely related to his

• A. early childhood experiences involving authority issues.
• B. anger about being hospitalized.
• C. low self-esteem.
• D. phobic fear of food.

Correct answer: C

Rationale: Psychotic clients often experience delusions due to difficulties with trust and low self-esteem (C). In this case, the client's belief that someone is trying to poison him is likely a manifestation of his underlying issues with trust and self-worth. Building trust and promoting positive self-esteem are essential in caring for such clients. Choices A, B, and D are incorrect because delusions are not primarily related to early childhood experiences involving authority issues, anger about hospitalization, or phobic fear of food. These factors do not directly contribute to the development of delusions in psychotic clients.

5. The nurse observes a client who is admitted to the mental health unit and identifies that the client is talking continuously, using words that rhyme but that have no context or relationship with one topic to the next in the conversation. This client's behavior and thought processes are consistent with which syndrome?

• A. Dementia
• B. Depression
• C. Schizophrenia
• D. Chronic brain syndrome

Correct answer: C

Rationale: The client is demonstrating symptoms of schizophrenia, such as disorganized speech that may include word salad (a type of communication that mixes real and imaginary words in no logical order), incoherent speech, and clanging (rhyming). Dementia (Choice A) is characterized by memory loss and cognitive decline, not by disorganized speech. Depression (Choice B) typically presents with persistent feelings of sadness and loss of interest, not disorganized speech. Chronic brain syndrome (Choice D) is a vague term and does not specifically describe the symptoms mentioned in the scenario.

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