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 leading a 'current events group' with chronic psychiatric clients. One group member states, 'Clara Barton was my nurse during my last hospitalization. She was a very mean nurse and wasn't nice to me.' Which response would be best for the nurse to make?
- A. 'Clara Barton was not your nurse.'
- B. 'What did she do to you that was so mean?'
- C. 'I didn't know that Clara Barton was a nurse.'
- D. 'Clara Barton started the American Red Cross.'
Correct Answer: D
Rationale: (D) presents the reality of the situation in relation to American culture. The fact that Clara Barton was a nurse during the Civil War should be addressed on an individual basis. Since this is group therapy, the nurse would be illustrating the concept of universality. (A) is likely to promote defensiveness. (B and C) would support the delusion. Therefore, the most appropriate response is (D) as it provides factual information that can redirect the conversation in a constructive manner.
A female client with obsessive compulsive personality disorder is admitted to the hospital for a cardiac catheterization. The afternoon before the procedure, the client begins to keep detailed notes of the nursing care she is receiving and reports her findings to the RN at bedtime. What action should the nurse implement?
- A. Explain to the client that her behavior invades the rights of the nursing staff.
- B. Ask the client to explain why she is keeping a detailed record of her nursing care.
- C. Teach the client strategies to control her obsessive compulsive behavior.
- D. Encourage the client to express her feelings regarding the upcoming procedure.
Correct Answer: D
Rationale: Encouraging the client to express her feelings can help address underlying anxieties and may reduce the need for obsessive behaviors. Choice A is incorrect because it may come across as confrontational and could escalate the situation. Choice B is not the best initial action as it focuses on the behavior rather than the client's emotions. Choice C is premature without first addressing the client's emotional needs.
The nurse asks a female client with borderline personality disorder, 'How do you feel about your children not coming to visit this weekend?' The client looks out the window and replies, 'I really don't care.' Which response is best for the nurse to provide?
- A. I noticed you were looking out the window when discussing your feelings.
- B. I think you're lying and it bothers you that your children aren't coming.
- C. I think you should discuss your children not coming in the group meeting.
- D. Why do you think your children didn't want to come visit you this weekend?
Correct Answer: A
Rationale: Acknowledging the client's non-verbal behavior, such as looking out the window, demonstrates active listening and provides the client with an opportunity to explore their feelings further. Choice B is incorrect as it accuses the client of lying without any evidence, which can damage the therapeutic relationship. Choice C is inappropriate as it dismisses the client's feelings and suggests a group discussion without addressing the client's emotions directly. Choice D is also incorrect as it focuses on the children's actions rather than the client's feelings, missing an opportunity for therapeutic communication.
A male client with schizophrenia tells the nurse that the voices he hears are saying, 'You must kill yourself.' To assist the client in coping with these thoughts, which response is best for the nurse to provide?
- A. Tell yourself that the voices are unreasonable.'
- B. Exercise when you hear the voices.'
- C. Talk to someone when you hear the voices.'
- D. The voices aren't real, so ignore them.'
Correct Answer: A
Rationale: The nurse should teach the client to use self-talk to disprove the voices. Although exercising may be helpful, the client's concrete thinking may make it difficult to understand this suggestion. Clients with schizophrenia have difficulty initiating interaction with others. Auditory hallucinations are often relentless, so it is difficult to ignore them.
When a client with schizophrenia is being discharged on antipsychotic medication, what is the most important instruction the nurse should provide?
- A. Stop the medication if you start feeling better.
- B. Be aware of the potential for weight gain with this medication.
- C. Report any unusual muscle movements immediately.
- D. You can drive as soon as you feel ready.
Correct Answer: C
Rationale: The correct answer is to instruct the client to report any unusual muscle movements immediately. These movements may indicate extrapyramidal symptoms (EPS) or tardive dyskinesia, which are serious side effects of antipsychotic medications that require immediate attention. Choice A is incorrect because stopping the medication without medical advice can lead to a relapse of symptoms. Choice B is important but not as critical as monitoring for EPS. Choice D is incorrect because driving readiness is not directly related to antipsychotic medication instructions.