Nokea
A client in a long-term care facility who has multiple sclerosis is embarrassed about the need to use a wheelchair and the muscle spasms that are readily visible in her legs. Which approach is therapeutic in assisting the client to cope?
- A. Keep the client in her room as much as possible
- B. Assist the client with all activities of daily living
- C. Tell the client that many of the people in the facility have these same sorts of problems
- D. Encourage and praise perseverance in performing ADLs, and assist the client to dress and groom daily
Correct Answer: D
Rationale: Encouraging and praising the client's perseverance in performing activities of daily living (ADLs) is therapeutic as it helps the client maintain a sense of normalcy and dignity, thus supporting their psychosocial well-being. This approach acknowledges the client's struggles while empowering them to maintain their independence and self-care. Choices A and C are incorrect as they do not address the client's emotional needs and may contribute to further isolation and distress. Choice B, while important, does not specifically address the client's feelings of embarrassment and the need for emotional support.
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A male client is admitted to the mental health unit because he was feeling depressed about the loss of his wife and job. The client has a history of alcohol dependency and admits that he was drinking alcohol 12 hours ago. Vital signs are: temperature, 100 F, pulse 100, and BP 142/100. The nurse plans to give the client lorazepam (Ativan) based on which priority nursing diagnosis?
- A. Risk for injury related to suicidal ideation.
- B. Risk for injury related to alcohol detoxification.
- C. Knowledge deficit related to ineffective coping.
- D. Health-seeking behaviors related to personal crisis.
Correct Answer: B
Rationale: The most important nursing diagnosis is related to alcohol detoxification (B) because the client has elevated vital signs, a sign of alcohol detoxification. Giving lorazepam (Ativan) to address the elevated vital signs due to alcohol withdrawal is a priority. Addressing the risk for injury related to suicidal ideation (A) should come after stabilizing the client's physiological state. Both (C) and (D) can be addressed once immediate safety needs are met, but the priority is managing the alcohol detoxification to prevent potential complications.
What is the priority intervention for a client with major depressive disorder admitted to the psychiatric unit with suicidal ideation?
- A. Conduct a thorough suicide risk assessment.
- B. Encourage the client to verbalize their feelings.
- C. Provide the client with positive affirmations.
- D. Refer the client to group therapy.
Correct Answer: A
Rationale: The correct answer is to conduct a thorough suicide risk assessment. When a client with major depressive disorder presents with suicidal ideation, the priority is to assess the level of risk to ensure the client's safety. This assessment helps determine the appropriate interventions, level of care, and monitoring needed. Encouraging the client to verbalize their feelings (choice B) is important, but not the priority when immediate safety is a concern. Providing positive affirmations (choice C) and referring the client to group therapy (choice D) may be beneficial interventions later on but do not address the immediate risk of harm to the client.
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: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. What information should the nurse explore in depth with the client based on this screening tool?
- A. Cancer screening results, anger, gastritis, daily alcohol intake.
- B. Efforts to cut down, annoyance with questions, guilt, drinking as an 'Eye-opener.'
- C. Consumption, liver enzyme, gastrointestinal complaints and bleeding.
- D. Minimizes drinking, frequently misses family events, guilt about drinking, amount of daily intake.
Correct Answer: B
Rationale: The CAGE questionnaire is used to identify problematic drinking behaviors. Choice B is correct because it includes key aspects that the nurse should explore further with the client. 'Efforts to cut down' can indicate acknowledgment of excessive drinking, 'guilt' reflects emotional distress related to drinking, and 'drinking as an 'Eye-opener'' suggests potential dependency. Choices A, C, and D are incorrect as they do not directly address the essential elements assessed by the CAGE questionnaire and may not provide relevant information for further evaluation of the client's drinking habits.
At a support meeting of parents of a teenager with polysubstance dependency, a parent states, 'Each time my son tries to quit taking drugs, he gets so depressed that I'm afraid he will commit suicide.' The nurse's response should be based on which information?
- A. Addiction is a chronic, incurable disease.
- B. Tolerance to the effects of drugs causes feelings of depression.
- C. Feelings of depression frequently lead to drug abuse and addiction.
- D. Careful monitoring should be provided during withdrawal from the drugs.
Correct Answer: C
Rationale: The correct response in this situation should focus on the connection between feelings of depression and drug abuse. Choice A is incorrect because addiction is treatable, not incurable. Choice B is incorrect as tolerance does not directly cause depression. Choice D is not the best response as the parent's concern is about the son's depression leading to suicidal thoughts, not just the withdrawal process.