Nursing Elites

1. The LPN/LVN is caring for a client who is experiencing alcohol withdrawal. Which intervention should the nurse implement first?

• A. Administer a PRN dose of lorazepam (Ativan).
• B. Monitor the client's vital signs.
• C. Place the client on seizure precautions.
• D. Encourage the client to express feelings about withdrawal.

Correct answer: B

Rationale: When caring for a client experiencing alcohol withdrawal, the first intervention the nurse should implement is to monitor the client's vital signs. Vital sign monitoring is crucial to assess for any potential complications such as hypertension, tachycardia, fever, or other signs of autonomic hyperactivity. Administering medication like lorazepam (Ativan) would come after assessing the vital signs to determine the need for pharmacological intervention. Placing the client on seizure precautions is important, but assessing vital signs takes precedence to ensure immediate safety. Encouraging the client to express feelings about withdrawal is a supportive intervention but does not address the immediate physiological risk associated with alcohol withdrawal.

2. Select the nursing interventions for a hospitalized client with mania who is exhibiting manipulative behavior. Select one intervention that does not apply.

• A. Communicate expected behaviors to the client
• B. Ensure that the client knows that he or she is not in charge of the nursing unit
• C. Assist the client in identifying ways of setting limits on personal behaviors
• D. Follow through about the consequences of behavior in a non-punitive manner

Correct answer: B

Rationale: The correct answer is B. Ensuring that the client knows they are not in charge of the nursing unit is not a helpful nursing intervention for managing manipulative behavior in a client with mania. Communicating expected behaviors, assisting with limit-setting, and following through on consequences in a non-punitive manner are more appropriate interventions to address manipulative behavior.

3. A male employee who is assessed weekly in the employee clinic for blood pressure because of a history of hypertension tells the nurse that he is so upset with one of his co-workers that he would like to shoot him. What action should the nurse take first?

• A. Determine if the client has a weapon available for use.
• B. Inform the health care provider of the threat to harm a co-worker.
• C. Notify security of the client's intention to harm a co-worker.
• D. Have the employee escorted to a mental health facility.

Correct answer: A

Rationale: Determining if the client has access to a weapon is critical for immediate safety and to prevent potential harm.

4. The nurse is leading a 'current events group' with chronic psychiatric clients. One group member states, 'Clara Barton was my nurse during my last hospitalization. She was a very mean nurse and wasn't nice to me.' Which response would be best for the nurse to make?

• A. 'Clara Barton was not your nurse.'
• B. 'What did she do to you that was so mean?'
• C. 'I didn't know that Clara Barton was a nurse.'
• D. 'Clara Barton started the American Red Cross.'

Correct answer: D

Rationale: (D) presents the reality of the situation in relation to American culture. The fact that Clara Barton was a nurse during the Civil War should be addressed on an individual basis. Since this is group therapy, the nurse would be illustrating the concept of universality. (A) is likely to promote defensiveness. (B and C) would support the delusion. Therefore, the most appropriate response is (D) as it provides factual information that can redirect the conversation in a constructive manner.

5. A 25-year-old female client has been particularly restless, and the nurse finds her trying to leave the psychiatric unit. She tells the nurse, 'Please let me go! I must leave because the secret police are after me.' Which response is best for the nurse to make?

• A. No one is after you; you're safe here.
• B. You'll feel better after you have rested.
• C. I know you must feel lonely and frightened.
• D. Come with me to your room, and I will sit with you.

Correct answer: D

Rationale: In this scenario, the best response for the nurse is to offer presence and a safe environment without validating the delusion or arguing with the client. By inviting the client to the room and offering to sit with her, the nurse is providing support and reassurance. Choice A is incorrect because directly denying the client's belief may escalate the situation. Choice B is inappropriate as it dismisses the client's concerns without addressing the underlying issue. Choice C acknowledges the client's feelings but does not provide immediate support or safety, unlike Choice D which offers both.

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