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. An 86-year-old female client with Alzheimer's disease is wandering the busy halls of the extended care facility and asks the nurse, "Where should I stand for the parade?" Which response is best for the LPN/LVN to provide?

• A. Anywhere you want to stand as long as you do not get hurt by those in the parade.
• B. You are confused because of all the activity in the hall. There is no parade.
• C. Let us go back to the activity room and see what is going on in there.
• D. Remember I told you that this is a nursing home and I am your nurse.

Correct answer: C

Rationale: Redirecting the client to a less confusing environment can help reduce anxiety and reorient her to reality.

3. 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.

4. Which client outcome indicates improvement for a client who is admitted with auditory hallucinations?

• A. Argues with the voices.
• B. Tells when voices decrease.
• C. Follows what the voices say.
• D. Tells the nurse what the voices say.

Correct answer: B

Rationale: The correct answer is B: 'Tells when voices decrease.' This outcome indicates improvement because it shows that the client is experiencing a reduction in auditory hallucinations. By communicating that the voices are decreasing, it suggests that the client's symptoms are improving and the treatment is effective. Choices A, C, and D are incorrect. Arguing with the voices (A) indicates ongoing engagement with the hallucinations, which is not a positive outcome. Following what the voices say (C) suggests compliance with the hallucinations, which is not indicative of improvement. Lastly, telling the nurse what the voices say (D) does not necessarily demonstrate a reduction in hallucinations or improvement in the client's condition.

5. A child is brought to the emergency room with a broken arm. Because of other injuries, the nurse suspects the child may be a victim of abuse. When the nurse tries to give the child an injection, the child's mother becomes very loud and shouts, 'I won't leave my son! Don't you touch him! You'll hurt my child!' What is the best interpretation of the mother's statements? The mother is

• A. regressing to an earlier behavior pattern.
• B. sublimating her anger.
• C. projecting her feelings onto the nurse.
• D. suppressing her fear.

Correct answer: C

Rationale: The correct answer is (C) projecting her feelings onto the nurse. The mother's behavior suggests that she is attributing her own actions or feelings to the nurse, which is a form of projection. Option (A) regressing to an earlier behavior pattern is not the best fit in this context. Option (B) sublimating her anger is not applicable based on the given scenario. Option (D) suppressing her fear cannot be inferred from the provided information.

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