Nursing Elites

1. The LPN/LVN is caring for a client who was recently diagnosed with a mental illness. The client asks, 'Will I be able to live a normal life?' What is the best response for the nurse to provide?

• A. Yes, you will be able to live a normal life.
• B. Many people with mental illness lead full and productive lives.
• C. It will depend on your treatment and the choices you make.
• D. There is no normal; everyone is unique in their own way.

Correct answer: C

Rationale: The best response for the nurse is to provide the client with hope while acknowledging the importance of their treatment and choices. Choice C addresses the client's concern by highlighting the impact of their treatment and personal choices on their future. It encourages personal responsibility and active participation in their recovery. Choices A and B may sound reassuring, but they do not empower the client to take an active role in their well-being. Choice D, while promoting individuality, does not directly address the client's question about living a normal life after a mental illness diagnosis.

2. A 46-year-old female client has been on antipsychotic neuroleptic medication for the past three days. She has had a decrease in psychotic behavior and appears to be responding well to the medication. On the fourth day, the client's blood pressure increases, she becomes pale and febrile, and demonstrates muscular rigidity. Which action will the nurse initiate?

• A. Place the client on seizure precautions and monitor closely.
• B. Immediately transfer the client to the ICU.
• C. Report the symptoms to the charge nurse and document in the client's chart.
• D. No action is required at this time as these are known side effects of such medications.

Correct answer: B

Rationale: These symptoms are indicative of neuroleptic malignant syndrome (NMS), which is a severe and life-threatening reaction to neuroleptic drugs. The major symptoms include fever, rigidity, autonomic instability, and encephalopathy. Respiratory failure, cardiovascular collapse, arrhythmias, and/or renal failure can lead to death. This is an emergency situation requiring immediate critical care, thus the correct action is to transfer the client to the ICU (B). Seizure precautions (A) are not relevant in this scenario. Merely describing the symptoms to the charge nurse and documenting them (C) or taking no action assuming these are common side effects (D) fail to address the critical nature of the situation and the urgency of immediate intervention.

3. A woman arrives in the Emergency Center and tells the nurse she thinks she has been raped. The client is sobbing and expresses disbelief that a rape could happen because the man is her best friend. After acknowledging the client's fear and anxiety, how should the nurse respond?

• A. I would be very upset and mad if my best friend did that to me.
• B. You must feel betrayed, but maybe you might have led him on?
• C. Rape is not limited to strangers and frequently occurs by someone who is known to the victim.
• D. This does not sound like rape. Did you change your mind about having sex after the fact?

Correct answer: C

Rationale: A victim of date rape or acquaintance rape is less prone to recognize what is happening because the incident usually involves persons who know each other and the dynamics are different than rape by a stranger. Choice (C) provides confrontation for the client's denial because the victim frequently knows and trusts the perpetrator. Nurses should not express personal feelings (Choice A) when dealing with victims. Choice B, suggesting that the client led on the rapist, indicates that the sexual assault was somehow the victim's fault. Choice D is judgmental and does not display compassion or establish trust between the nurse and the client.

4. The RN is providing education about strategies for a safety plan for a female client who is a victim of intimate partner violence. Which strategies should be included in the safety plan? (select one that does not apply)

• A. Purchase a gun to use for protection.
• B. Keep quiet and calm.
• C. Take a self-defense course that retaliates against the abuser with injury.
• D. Have a bag ready that has extra clothes for self and children.

Correct answer: C

Rationale: Taking a self-defense course that retaliates against the abuser with injury can escalate the level of violence and is not recommended in a safety plan for a victim of intimate partner violence. The correct strategies include establishing a code, having a bag ready, and planning an escape route, which enhance safety without increasing the risk of harm.

5. 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.

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