Nursing Elites

1. During initial assessment of the teenager, what information is most important for the nurse to obtain from the parents?

• A. If he has seemed depressed recently.
• B. If a drug overdose has ever occurred before.
• C. If he might have taken any other drugs.
• D. If he has a desire to quit taking drugs.

Correct answer: C

Rationale: The correct answer is C. It's crucial to determine if the teenager might have taken other substances besides the pain pills mentioned by the mother. This information is vital for effective treatment because knowing the full scope of substances involved helps in managing potential interactions, side effects, and the overall condition of the patient. Options A, B, and D are not as critical in the immediate assessment compared to knowing if the teenager has ingested any other drugs.

2. A client with schizophrenia is being treated with clozapine (Clozaril). What laboratory test is most important for the nurse to monitor?

• A. Liver function tests
• B. Kidney function tests
• C. White blood cell count
• D. Blood glucose levels

Correct answer: C

Rationale: The correct answer is C: White blood cell count. Clozapine can lead to agranulocytosis, a severe drop in white blood cells, which can be life-threatening. Monitoring the white blood cell count is crucial to detect this condition early. Choices A, B, and D are incorrect because while liver and kidney function tests are important in monitoring other aspects of health, the most critical concern with clozapine therapy is the risk of agranulocytosis, making monitoring white blood cell count the priority.

3. A male hospital employee is pushed out of the way by a female employee because of an oncoming gurney. The pushed employee becomes very angry and swings at the female employee. Both employees are referred for counseling with the staff psychiatric nurse. Which factor in the pushed employee's history is most related to the reaction that occurred?

• A. Is worried about losing his job to a woman
• B. Tortured animals as a child
• C. Was physically abused by his mother
• D. Hates to be touched by anyone

Correct answer: C

Rationale: The correct answer is C: 'Was physically abused by his mother.' A history of physical abuse can lead to heightened responses to physical contact. In this scenario, the employee's reaction of becoming very angry and swinging at the female employee after being pushed may be influenced by past experiences of physical abuse. This history can contribute to increased sensitivity to physical interactions and may trigger defensive or aggressive responses. Choices A, B, and D are less directly related to the employee's reaction in this specific context. While worrying about losing his job to a woman could contribute to underlying stress or insecurity, torturing animals as a child reflects a different type of behavioral issue, and hating to be touched by anyone suggests personal boundaries unrelated to the observed behavior in this scenario.

4. A client with generalized anxiety disorder is being treated with lorazepam (Ativan). What is the most important teaching point for the LPN/LVN to reinforce?

• A. Take the medication on an empty stomach.
• B. Avoid drinking alcohol while taking this medication.
• C. This medication may cause drowsiness, so avoid driving.
• D. You can stop taking the medication once you feel better.

Correct answer: B

Rationale: The most important teaching point for the LPN/LVN to reinforce is to avoid drinking alcohol while taking lorazepam (Ativan). Alcohol can enhance the sedative effects of lorazepam, increasing the risk of severe side effects and complications. Choice A is incorrect because lorazepam can be taken with or without food. Choice C is not the most critical teaching point, although it is essential to avoid activities that require mental alertness until the effects of the medication are known. Choice D is incorrect because abruptly stopping lorazepam can lead to withdrawal symptoms and should only be done under medical supervision.

5. A male client who is participating in an anger management assignment asks if he can make a leather belt in occupational therapy. The client begins pounding the leather vigorously with a mallet to imprint designs on the belt. What defense mechanism is the client using?

• A. Sublimation
• B. Suppression
• C. Regression
• D. Compensation

Correct answer: A

Rationale: The correct answer is A, Sublimation. Sublimation is a defense mechanism where unacceptable impulses are redirected into socially acceptable activities, such as art or work. In this scenario, the client is channeling his anger into a creative and constructive task like making a leather belt. Choice B, Suppression, involves consciously pushing down or hiding feelings rather than expressing them through alternate means. Choice C, Regression, refers to reverting to earlier, immature behaviors when faced with stress. Choice D, Compensation, involves making up for a perceived weakness in one area by excelling in another, which is not demonstrated in the scenario provided.

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