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A client who has recently been diagnosed with schizophrenia tells the LPN/LVN, 'I hear voices telling me to hurt myself.' What is the most appropriate nursing action?
- A. Encourage the client to ignore the voices.
- B. Tell the client that the voices will go away with medication.
- C. Monitor the client for signs of self-harm.
- D. Refer the client for a psychiatric evaluation.
Correct Answer: D
Rationale: The correct answer is to refer the client for a psychiatric evaluation. The client's statement indicating hearing voices telling them to hurt themselves is a serious concern and suggests a risk for self-harm. Referring the client for a psychiatric evaluation is crucial for further assessment and intervention by mental health professionals. Choice A is incorrect because ignoring the voices may not address the client's safety. Choice B is incorrect as it oversimplifies the situation and does not address the immediate risk. Choice C is not as comprehensive as referring for a psychiatric evaluation, which is necessary in this situation.
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During the manic phase of bipolar disorder, what is the priority nursing intervention for a female client who has not slept for the past 48 hours, is hyperactive, talkative, and engaging in risky behaviors?
- A. Encourage the client to participate in a quiet activity.
- B. Provide a safe environment and limit stimuli.
- C. Administer a sedative to help the client sleep.
- D. Discuss the consequences of her risky behaviors.
Correct Answer: B
Rationale: The correct priority nursing intervention for a female client in the manic phase of bipolar disorder, who has not slept for 48 hours, is hyperactive, talkative, and engaging in risky behaviors, is to provide a safe environment and limit stimuli. This approach is crucial to prevent harm to the client and others. Encouraging a quiet activity (Choice A) may not effectively address the need for safety during the manic phase. Administering a sedative (Choice C) should be done under the guidance of a healthcare provider and does not address the immediate safety concerns. Discussing consequences of risky behaviors (Choice D) may not be effective during the manic phase when the client's judgment is impaired.
A client with a diagnosis of major depressive disorder is prescribed fluoxetine (Prozac). What is the most important side effect for the LPN/LVN to monitor?
- A. Weight gain.
- B. Sexual dysfunction.
- C. Nausea.
- D. Constipation.
Correct Answer: B
Rationale: The correct answer is B: Sexual dysfunction. When monitoring a client taking fluoxetine (Prozac), the LPN/LVN should prioritize observing for sexual dysfunction. This side effect is crucial to monitor as it can significantly impact the client's quality of life and may affect their adherence to the medication. Weight gain (choice A) is a possible side effect of fluoxetine but is not as critical as sexual dysfunction in terms of monitoring. Nausea (choice C) and constipation (choice D) are common side effects of fluoxetine, but they are generally less concerning compared to the impact of sexual dysfunction on the client's well-being and treatment compliance.
An LPN/LVN is conducting an initial assessment on a client in crisis. When assessing the client's perception of the precipitating event that led to the crisis, the appropriate question to ask is:
- A. With whom do you live?
- B. Who is available to help you?
- C. What leads you to seek help now?
- D. What do you usually do to feel better?
Correct Answer: C
Rationale: The correct question to ask when assessing a client's perception of the precipitating event that led to a crisis is 'What leads you to seek help now?' This question directly addresses the client's current situation and triggers that brought them to seek assistance. Choices A and B are more focused on the client's social support system rather than the root cause of the crisis. Choice D addresses coping mechanisms rather than the actual trigger for seeking help.
A client who has been admitted to the psychiatric unit tells the nurse, 'My problems are so bad that no one can help me.' Which response is best for the nurse to make?
- A. How can I help?
- B. Things probably aren't as bad as they seem right now.
- C. Let's talk about what is right with your life.
- D. I hear how miserable you are, but things will get better soon.
Correct Answer: A
Rationale: Offering self shows empathy and caring (A) and is the best choice provided. (B) dismisses the client's feelings and reality. (C) avoids addressing the client's concerns directly and may come across as invalidating. Although (D) starts with acknowledging the client's feelings, the second part about things getting better soon can be perceived as offering false reassurance, which is not recommended in therapeutic communication.
A client with obsessive-compulsive disorder (OCD) spends several hours a day washing his hands. What is the most therapeutic nursing intervention?
- A. Allow the client to continue the behavior to reduce anxiety.
- B. Schedule specific times for handwashing.
- C. Encourage the client to discuss the thoughts and feelings behind the behavior.
- D. Restrict the client's access to soap and water.
Correct Answer: C
Rationale: Encouraging the client to discuss the thoughts and feelings behind the behavior is the most therapeutic nursing intervention for a client with OCD who excessively washes hands. This approach can help the client understand the underlying reasons for the behavior, address the associated anxiety, and work toward behavior modification. Choices A, allowing the behavior to continue, and D, restricting access to soap and water, do not address the root cause of the behavior and may exacerbate anxiety. Choice B, scheduling specific times for handwashing, does not address the underlying emotional factors contributing to the behavior and may not effectively reduce the client's anxiety.