Nursing Elites

1. 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.

2. What is the most therapeutic nursing response for a client with borderline personality disorder who engages in self-mutilating behavior?

• A. Encourage the client to stop hurting themselves.
• B. Discuss what the client was feeling before self-harming.
• C. Inform the client that the behavior will be reported to their doctor.
• D. Ask the client why they hurt themselves.

Correct answer: B

Rationale: The most therapeutic nursing response for a client with borderline personality disorder engaging in self-mutilating behavior is to discuss what the client was feeling before self-harming. This approach helps in exploring the underlying triggers and emotions that lead to self-harm. Option A is directive and may come across as judgmental rather than empathetic. Option C can lead to feelings of betrayal and breach of trust. Option D is a closed-ended question that may not facilitate open communication or exploration of emotions.

3. A young adult male client, diagnosed with paranoid schizophrenia, believes that the world is trying to poison him. What intervention should the nurse include in this client's plan of care?

• A. Remind the client that his suspicions are not true
• B. Ask one nurse to spend time with the client daily
• C. Encourage the client to participate in group activities
• D. Assign the client to a room closest to the activity room

Correct answer: B

Rationale: The correct intervention for a client diagnosed with paranoid schizophrenia who believes in paranoid delusions is to ask one nurse to spend time with the client daily. Establishing a trusting relationship with a consistent caregiver can help reduce anxiety and foster a sense of security. Choice A is incorrect because directly challenging the client's beliefs may increase distress. Choice C might overwhelm the client with paranoia in a group setting. Choice D does not address the need for a trusting relationship with a specific caregiver.

4. A client with generalized anxiety disorder is being treated with lorazepam (Ativan). What is the most important teaching point for the LPN/LVN to reinforce?

• A. Take the medication on an empty stomach.
• B. Avoid drinking alcohol while taking this medication.
• C. This medication may cause drowsiness, so avoid driving.
• D. You can stop taking the medication once you feel better.

Correct answer: B

Rationale: The most important teaching point for the LPN/LVN to reinforce is to avoid drinking alcohol while taking lorazepam (Ativan). Alcohol can enhance the sedative effects of lorazepam, increasing the risk of severe side effects and complications. Choice A is incorrect because lorazepam can be taken with or without food. Choice C is not the most critical teaching point, although it is essential to avoid activities that require mental alertness until the effects of the medication are known. Choice D is incorrect because abruptly stopping lorazepam can lead to withdrawal symptoms and should only be done under medical supervision.

5. A client who has recently been diagnosed with schizophrenia tells the LPN/LVN, 'I hear voices telling me to hurt myself.' What is the most appropriate nursing action?

• A. Encourage the client to ignore the voices.
• B. Tell the client that the voices will go away with medication.
• C. Monitor the client for signs of self-harm.
• D. Refer the client for a psychiatric evaluation.

Correct answer: D

Rationale: The correct answer is to refer the client for a psychiatric evaluation. The client's statement indicating hearing voices telling them to hurt themselves is a serious concern and suggests a risk for self-harm. Referring the client for a psychiatric evaluation is crucial for further assessment and intervention by mental health professionals. Choice A is incorrect because ignoring the voices may not address the client's safety. Choice B is incorrect as it oversimplifies the situation and does not address the immediate risk. Choice C is not as comprehensive as referring for a psychiatric evaluation, which is necessary in this situation.

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