Nokea
A client with a leg amputation is upset about his appearance. The LPN/LVN intends to address which most closely associated psychosocial problem?
- A. Inability to be mobile
- B. Isolating self from others
- C. Inability to tolerate activity
- D. Concern about body persona
Correct Answer: D
Rationale: The correct answer is D. A client with a leg amputation being upset about his appearance is most closely associated with concerns about body image and self-perception. This individual may be worried about how others perceive them, impacting their self-esteem and overall well-being. Choices A, B, and C are incorrect because the primary psychosocial issue in this scenario is related to body image and self-perception, not mobility, social isolation, or activity tolerance.
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The nurse is admitting a male client who takes lithium carbonate (Eskalith) twice a day. Which information should the nurse report to the healthcare provider immediately?
- A. Short-term memory loss.
- B. Depressed affect.
- C. Five-pound weight gain.
- D. Nausea and vomiting.
Correct Answer: D
Rationale: Nausea and vomiting should be reported immediately because they could indicate lithium toxicity, which requires urgent medical attention to prevent more severe effects. Short-term memory loss, depressed affect, and weight gain are common side effects of lithium but do not require immediate medical attention compared to symptoms of toxicity like nausea and vomiting.
A nurse working on a mental health unit receives a community call from a person who is tearful and states, 'I just feel so nervous all of the time. I don't know what to do about my problems. I haven't been able to sleep at night and have hardly eaten for the past 3 or 4 days.' The nurse should initiate a referral based on which assessment?
- A. Altered thought processes.
- B. Moderate levels of anxiety.
- C. Inadequate social support.
- D. Altered health maintenance.
Correct Answer: B
Rationale: The nurse should initiate a referral based on moderate levels of anxiety (B) as the client reports feeling nervous all the time, sleep disturbances, poor appetite, and difficulty solving problems. These symptoms are indicative of significant anxiety levels. The client does not mention symptoms related to altered thought processes (A) or inadequate social support (C). There is insufficient information to suggest altered health maintenance (D) as a reason for referral in this scenario.
A client with bipolar disorder is prescribed valproic acid (Depakote). What is the most important laboratory test for the LPN/LVN to monitor?
- A. Liver function tests.
- B. Kidney function tests.
- C. Thyroid function tests.
- D. Complete blood count.
Correct Answer: A
Rationale: The correct answer is A: Liver function tests. Monitoring liver function tests is crucial for clients prescribed valproic acid (Depakote) due to the medication's potential to affect liver function and increase the risk of liver toxicity. While kidney function tests (choice B), thyroid function tests (choice C), and complete blood count (choice D) are important in various clinical scenarios, the priority when administering valproic acid is to monitor liver function to prevent adverse effects associated with this medication.
A client with anorexia nervosa is being treated in an inpatient unit. Which intervention is a priority for the nurse?
- A. Encourage the client to exercise to build muscle mass.
- B. Provide liquid supplements between meals.
- C. Allow the client to choose their own meals.
- D. Monitor the client's weight daily.
Correct Answer: D
Rationale: Monitoring the client's weight daily is a priority intervention for a nurse caring for a client with anorexia nervosa. Weight monitoring is crucial in assessing the client's progress and adjusting treatment as necessary to prevent complications such as refeeding syndrome, electrolyte imbalances, and cardiac issues. Encouraging exercise (Choice A) can exacerbate the client's unhealthy relationship with food and body image. Providing liquid supplements (Choice B) is important but may not be the priority over monitoring weight. Allowing the client to choose their own meals (Choice C) may not be suitable initially as they may make unhealthy choices or avoid meals altogether.
The nurse is conducting discharge teaching for a client with schizophrenia who plans to live in a group home. Which statement is most indicative of the need for careful follow-up after discharge?
- A. Crickets are a good source of protein.
- B. I have not heard any voices for a week.
- C. Only my belief in God can help me.
- D. Sometimes I have a hard time sitting still.
Correct Answer: C
Rationale: The correct answer is C. The statement 'Only my belief in God can help me' suggests a reliance on spiritual intervention over medical treatment, raising concerns about potential non-compliance. This indicates the need for close follow-up to ensure the client's well-being and adherence to the prescribed treatment plan. Choices A, B, and D do not directly address potential issues related to treatment compliance or the need for follow-up care after discharge.