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 a leg amputation is upset about his appearance. The LPN/LVN intends to address which most closely associated psychosocial problem?

• A. Inability to be mobile
• B. Isolating self from others
• C. Inability to tolerate activity
• D. Concern about body persona

Correct answer: D

Rationale: The correct answer is D. A client with a leg amputation being upset about his appearance is most closely associated with concerns about body image and self-perception. This individual may be worried about how others perceive them, impacting their self-esteem and overall well-being. Choices A, B, and C are incorrect because the primary psychosocial issue in this scenario is related to body image and self-perception, not mobility, social isolation, or activity tolerance.

3. A client with obsessive-compulsive disorder (OCD) is hospitalized for treatment. Which intervention is most important for the LPN/LVN to include in the client's plan of care?

• A. Allow the client to engage in compulsive behaviors as a way to reduce anxiety.
• B. Encourage the client to ignore the compulsive behaviors.
• C. Help the client to understand the purpose of compulsive behaviors.
• D. Work with the client to gradually reduce the frequency of compulsive behaviors.

Correct answer: D

Rationale: The correct intervention for a client with OCD is to work with them to gradually reduce the frequency of compulsive behaviors. This approach helps the client manage their condition effectively without causing undue distress. Allowing the client to engage in compulsive behaviors can reinforce the disorder rather than alleviate it. Encouraging the client to ignore compulsive behaviors does not address the core issue of OCD. While helping the client understand the purpose of compulsive behaviors can be beneficial, actively working to reduce these behaviors is more crucial in the treatment of OCD.

4. The nurse should hold the next scheduled dose of a client's haloperidol (Haldol) based on which assessment finding(s)?

• A. Dizziness when standing.
• B. Shuffling gait and hand tremors.
• C. Urinary retention.
• D. Fever of 102°F.

Correct answer: D

Rationale: A fever (D) may indicate neuroleptic malignant syndrome (NMS), a potentially fatal complication of antipsychotics. The healthcare provider should be contacted before administering the next dose of Haldol. Dizziness when standing (A), shuffling gait and hand tremors (B), and urinary retention (C) are all adverse effects of Haldol that, while concerning, do not pose immediate life-threatening risks compared to the potential severity of NMS indicated by a fever.

5. When caring for a client with borderline personality disorder in a psychiatric unit, what is the most therapeutic nursing intervention?

• A. Set clear and consistent boundaries for the client.
• B. Allow the client to vent their feelings without interruption.
• C. Encourage the client to participate in group therapy.
• D. Provide the client with frequent reassurance and support.

Correct answer: A

Rationale: Setting clear and consistent boundaries is the most therapeutic nursing intervention when caring for a client with borderline personality disorder. This approach provides structure, promotes predictability, and helps prevent manipulative behaviors. By establishing boundaries, the nurse can maintain a safe therapeutic relationship with the client. Allowing the client to vent their feelings without interruption (Choice B) may not always be beneficial, as it could reinforce maladaptive behaviors. Encouraging participation in group therapy (Choice C) can be helpful but setting boundaries is more critical for individualized care. Providing the client with frequent reassurance and support (Choice D) may not address the underlying issues and can contribute to dependency rather than fostering independence and coping skills.

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