Nursing Elites

1. Which information should the LPN/LVN exclude in the nursing plan of care for a client with obsessive-compulsive disorder (OCD)?

• A. The medical diagnosis of the client
• B. Individualized goals and objectives
• C. Attendance at group therapy sessions
• D. Self-care measures to improve hygiene

Correct answer: A

Rationale: The correct answer is A because including the medical diagnosis of the client in the nursing plan is redundant as the healthcare team is already aware of the diagnosis. The nursing plan of care for a client with OCD should focus on individualized goals, objectives, attendance at group therapy sessions, and self-care measures to improve hygiene. These components directly contribute to addressing the client's needs and promoting recovery. Therefore, the medical diagnosis does not need to be included in the nursing plan as it does not actively guide the day-to-day care and interventions for the client.

2. A client with major depressive disorder is being treated with cognitive-behavioral therapy (CBT). Which client statement indicates that CBT is having a positive effect?

• A. "I understand now that my negative thoughts are not always true."
• B. "I still feel down, but I am able to go to work."
• C. "I have stopped taking my antidepressant medication."
• D. "I avoid situations that make me feel anxious."

Correct answer: A

Rationale: The correct answer is A. Recognizing and challenging negative thoughts is a fundamental aspect of cognitive-behavioral therapy (CBT). In this statement, the client demonstrates insight into the fact that their negative thoughts may not always be accurate, showing progress in reframing their thoughts. Choice B indicates some improvement in functioning but does not directly relate to the core principles of CBT. Choice C is concerning as abruptly stopping antidepressant medication can be detrimental to the client's well-being. Choice D reflects avoidance behavior, which is typically a target for intervention in CBT rather than a sign of positive progress.

3. The nurse is conducting discharge teaching for a client with schizophrenia who plans to live in a group home. Which statement is most indicative of the need for careful follow-up after discharge?

• A. Crickets are a good source of protein.
• B. I have not heard any voices for a week.
• C. Only my belief in God can help me.
• D. Sometimes I have a hard time sitting still.

Correct answer: C

Rationale: The correct answer is C. The statement 'Only my belief in God can help me' suggests a reliance on spiritual intervention over medical treatment, raising concerns about potential non-compliance. This indicates the need for close follow-up to ensure the client's well-being and adherence to the prescribed treatment plan. Choices A, B, and D do not directly address potential issues related to treatment compliance or the need for follow-up care after discharge.

4. The LPN/LVN is caring for a client who has been prescribed lithium carbonate. What is the most important instruction for the nurse to provide?

• A. Take the medication with food to avoid stomach upset.
• B. Do not change your salt intake while on this medication.
• C. Drink plenty of water and maintain a consistent salt intake.
• D. Avoid excessive intake of caffeine while on this medication.

Correct answer: B

Rationale: The most important instruction for a client prescribed lithium carbonate is not to change their salt intake. Alterations in sodium levels can impact lithium levels, leading to an increased risk of toxicity. Choice A is not crucial for lithium carbonate administration. While hydration is essential, maintaining a consistent salt intake is more critical than just increasing water intake (Choice C). Although caffeine can interact with lithium, it is not as important as maintaining a consistent salt intake (Choice D).

5. A client with schizophrenia is being treated with haloperidol (Haldol). The LPN/LVN observes the client pacing in the hallway and appearing anxious. What should the nurse do first?

• A. Ask the client to sit down and relax.
• B. Administer a PRN dose of antipsychotic medication.
• C. Encourage the client to talk about what is making him anxious.
• D. Monitor the client for adverse reactions to the medication.

Correct answer: B

Rationale: Administering a PRN dose of antipsychotic medication is the first action the nurse should take to manage symptoms of anxiety in a client being treated with haloperidol. The priority is to address the client's escalating anxiety and pacing behavior, which can be managed effectively by providing additional antipsychotic medication. Asking the client to sit down and relax (Choice A) may not be effective if the anxiety is due to inadequate medication levels. Encouraging the client to talk about what is making him anxious (Choice C) may not be beneficial in this acute situation and can be considered after addressing the immediate need for symptom management. Monitoring for adverse reactions (Choice D) is important but is not the first action to take when the client is showing signs of increasing anxiety and agitation.

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