Nokea
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.
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A 45-year-old male client tells the nurse that he used to believe that he was Jesus Christ, but now he knows he is not. Which response is best for the nurse to make?
- A. Did you really believe you were Jesus Christ?
- B. I think you're getting well.
- C. Others have had similar thoughts when under stress.
- D. Why did you think you were Jesus Christ?
Correct Answer: C
Rationale: Choice C is the best response because it validates the client's experience by acknowledging that others have had similar thoughts when under stress. This response helps normalize the client's past experiences without judgment, fostering a supportive and empathetic environment. Choices A and D may come off as judgmental or confrontational, potentially making the client feel misunderstood or defensive. Choice B, 'I think you're getting well,' does not address the client's past belief or provide the understanding and validation that Choice C offers.
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.
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.
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 nurse to provide?
- A. "You can stand wherever you'd like as long as you stay safe from those in the parade."
- B. "You seem confused because of all the activity in the hall. There is no parade."
- C. "Let's go back to the activity room and see what is going on in there."
- D. "Remember, this is a nursing home, and I am here to help you."
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A female client with depression attends group and states that she sometimes misses her medication appointments because she feels very anxious about riding the bus. Which statement is the nurse's best response?
- A. Can your case manager take you to your appointments?
- B. Take your medication for anxiety before you ride the bus.
- C. Let's talk about what happens when you feel very anxious.
- D. What are some ways that you can cope with your anxiety?
Correct Answer: D
Rationale: The best response is to explore ways for the client to cope with anxiety (D). The nurse should encourage problem-solving rather than dependence on the case manager (A) for transportation. While taking medication for anxiety before riding the bus may be helpful, addressing coping strategies should come first (B). Although discussing the feelings of anxiety can be therapeutic (C), the most appropriate approach is to engage the client in finding ways to manage her anxiety effectively.