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At what point in the nurse-patient relationship should a nurse plan to first address termination?
- A. During the orientation phase
- B. At the end of the working phase
- C. Near the beginning of the termination phase
- D. When the patient initially brings up the topic
Correct Answer: A
Rationale: Addressing termination early, during the orientation phase, sets clear expectations and prepares the patient for the relationship’s end, enhancing trust. Options B and C delay this discussion, and Option D leaves it to the patient, which may lead to uncertainty.
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A Chinese American patient diagnosed with an anxiety disorder says,My problems began when my energy became imbalanced. The nurse asks for the patients ideas about how to treat the imbalance. Which comment would the nurse expect from this patient?
- A. My family will bring special foods to help me get well.
- B. I hope my health care provider will prescribe some medication to help me.
- C. I think I would benefit from talking to other patients with a similar problem.
- D. I would like to have a native healer perform a ceremony to balance my energy.
Correct Answer: A
Rationale: The concept of energy imbalance as a source of illness is an explanatory model familiar to Asian cultures. A source of healing is dietary change to include either hot or cold foods to correct the imbalance. Hot and cold in this case do not refer to thermal properties of the foods. Medication would not be a treatment suggested by a patient with an Eastern worldview. Someone from an indigenous culture may suggest rituals. Group discussion of mental illness would not be appealing to a Chinese American.
A nurse asks a patient, 'If you had fever and vomiting for 3 days, what would you do?' Which aspect of the mental status examination is the nurse assessing?
- A. Behavior
- B. Cognition
- C. Affect and mood
- D. Perceptual disturbances
Correct Answer: B
Rationale: Assessing cognition involves determining a patient's judgment and decision making. In this case, the nurse would expect a response of 'Call my doctor' if the patient's cognition and judgment are intact. If the patient responds, 'I would stop eating' or 'I would just wait and see what happened,' the nurse would conclude that judgment is impaired. The other options refer to other aspects of the examination.
A nurse is assessing a patient diagnosed with major depressive disorder. The patient expresses feelings of hopelessness and states, 'I don't think anything will ever improve.' What is the priority nursing intervention?
- A. Encourage the patient to engage in activities that improve mood.
- B. Assess the patient for suicidal thoughts and ideation.
- C. Provide the patient with positive affirmations and reassurances.
- D. Suggest that the patient take medications to help with their depression.
Correct Answer: B
Rationale: The priority intervention is to assess the patient's risk for suicide, as feelings of hopelessness can indicate a high risk for self-harm. Immediate action is necessary to ensure safety.
The role of the LPN/LVN to the nursing process is (select all that apply):
- A. Assisting the registered nurse with the nursing diagnosis.
- B. Collecting data.
- C. Completing the initial assessment.
- D. Developing principles of teaching.
Correct Answer: A
Rationale: The LPN/LVN can assist the registered nurse with the nursing diagnosis. The nursing diagnosis is the responsibility of the registered nurse. The LPN/LVN can collect data in order to implement care.
During the admission assessment, the nurse asks the client, 'How are you feeling?' The client responds, 'I was able to purchase gas for 7 cents a gallon less than yesterday, which saved me a total of 84 cents. My car has a 12-gallon gas tank. Usually I am able to put in 11.7 gallons. I am very happy to have saved so much money.' The nurse recognizes this response as which of the following?
- A. Circumstantial thinking
- B. Echolalia
- C. Flight of ideas
- D. Neologisms
Correct Answer: A
Rationale: With circumstantial thinking, the client eventually answers a question but only after giving excessive unnecessary detail. Echolalia is repetition or imitation of what someone else says. Flight of ideas is excessive amount and rate of speech composed of fragmented or unrelated ideas. Neologisms are invented words that have meaning only for the client.