Nursing Elites

1. The LPN/LVN should include which interventions in the plan of care for a severely depressed client with neurovegetative symptoms? (select one that does not apply.)

• A. Permit rest periods as needed.
• B. Speaking slowly and simply.
• C. Place the client on suicide precautions.
• D. Limit and discourage food and fluid intake.

Correct answer: D

Rationale: For a severely depressed client with neurovegetative symptoms, the care plan should include rest, simple communication, suicide precautions, monitoring intake, and encouraging mild exercise. Limiting and discouraging food and fluid intake is not appropriate as proper nutrition and hydration are essential for overall well-being. This choice could lead to further complications and is not recommended in the care of a depressed client.

2. A client on the psychiatric unit appears to imitate a certain nurse on the unit. The client seeks out this particular nurse and imitates the nurse's mannerisms. The nurse knows that the client is using which defense mechanism?

• A. Sublimation.
• B. Identification.
• C. Introjection.
• D. Repression.

Correct answer: B

Rationale: The correct answer is (B) Identification. In this scenario, the client is imitating the nurse's mannerisms, which is a form of identification, a defense mechanism where an individual adopts the characteristics or behaviors of someone they admire or view as powerful. (A) Sublimation involves channeling unacceptable impulses into socially acceptable actions, not imitation. (C) Introjection is the internalization of external qualities or attributes, not imitation. (D) Repression is the unconscious exclusion of painful thoughts or memories from awareness, which is not demonstrated in this case.

3. A male client with alcohol dependence is admitted for detoxification. The nurse knows that which assessment finding is indicative of alcohol withdrawal?

• A. Bradycardia
• B. Hypotension
• C. Tremors
• D. Hyperglycemia

Correct answer: C

Rationale: Tremors are a common sign of alcohol withdrawal. The central nervous system becomes hyperexcitable due to the suppression caused by chronic alcohol intake. Tremors are a manifestation of this hyperexcitability and are a key indicator of alcohol withdrawal. Bradycardia and hypotension are more commonly associated with conditions like shock or severe dehydration rather than alcohol withdrawal. Hyperglycemia is not a typical finding in alcohol withdrawal; instead, hypoglycemia is more commonly seen due to the effects of alcohol on glucose metabolism.

4. A male client is admitted to the psychiatric unit with a medical diagnosis of paranoid schizophrenia. During the admission procedure, the client looks up and states, 'No, it's not MY fault. You can't blame me. I didn't kill him, you did.' What action is best for the nurse to take?

• A. Reassure the client by telling him that his fear of the admission procedure is to be expected.
• B. Tell the client that no one is accusing him of murder and remind him that the hospital is a safe place.
• C. Assess the content of the hallucinations by asking the client what he is hearing.
• D. Ignore the behavior and make no response at all to his delusional statements.

Correct answer: C

Rationale: The correct action for the nurse to take in this situation is to assess the content of the hallucinations by asking the client what he is hearing (C). Further assessment is needed to understand the nature of the client's delusions and hallucinations. Choice A is incorrect as it focuses on reassuring the client about his fear, which is not addressing the underlying issue of the delusional statement. Choice B is incorrect as it argues with the client's delusion and offers false reassurance, which is not therapeutic. Choice D is incorrect as ignoring the behavior and making no response disregards the client's needs for assessment and support.

5. A 20-year-old female client with schizophrenia is scheduled to receive risperidone (Risperdal) 2mg at bedtime. When the nurse attempts to administer the medication, the client states, 'I am not going to take that medicine, and you can't make me.' What action should the nurse take?

• A. Administer the medication via a nasogastric tube.
• B. Substitute an injectable form of the medication.
• C. Encourage the client to take the medicine because it will help her sleep.
• D. Document in the client's record that the medication was refused.

Correct answer: D

Rationale: In this scenario, the correct action for the nurse to take is to respect the client's autonomy and decision-making capacity. It's crucial to document the medication refusal accurately in the client's record. Administering the medication via a nasogastric tube or substituting it with an injectable form would violate the client's right to refuse treatment and should only be considered in extreme cases after consulting with the healthcare team. Encouraging the client to take the medication because it will help her sleep disregards her autonomy and choice in the matter.

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