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Physical examination of a 6-year-old reveals several bite marks in various locations on his body. X-ray examination reveals healed fractures of the ribs. The mother tells the nurse that her child is always having accidents. Which initial response by the nurse is most appropriate?
- A. I need to inform the healthcare provider about your child's tendency to be accident-prone.
- B. Tell me more specifically about your child's accidents.
- C. I must report these injuries to the authorities because they do not seem accidental.
- D. Boys this age always seem to require more supervision and can be quite accident-prone.
Correct Answer: B
Rationale: (B) seeks more information in a non-threatening manner to gather additional details about the child's accidents. This response allows the nurse to explore the situation further without making assumptions. (A) fails to address the concerning findings and instead focuses on informing the healthcare provider. (C) jumps to conclusions without gathering more information, potentially causing unnecessary distress to the family. (D) dismisses the seriousness of the situation by attributing the injuries to common accidents for boys, missing the opportunity to delve deeper into the issue.
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The LPN/LVN is caring for a client with depression who has been prescribed an SSRI. The client reports feeling more energy but is still feeling hopeless. What should the nurse be most concerned about?
- A. That the client may act on suicidal thoughts.
- B. That the client may engage in impulsive behavior.
- C. That the client may be experiencing the side effects of the medication.
- D. That the client may be at risk for developing serotonin syndrome.
Correct Answer: A
Rationale: The nurse should be most concerned that the client may act on suicidal thoughts. An increase in energy combined with persistent feelings of hopelessness can indicate a higher risk of suicide. While impulsive behavior can be a concern, the primary worry should be the client's safety regarding suicidal ideation. Side effects of the medication are important to monitor but do not take precedence over the risk of self-harm. Serotonin syndrome is a potential concern with SSRIs, but in this scenario, the client's mental health and safety are the immediate priority.
During the admission assessment, a female client requests that her husband be allowed to stay in the room. While interviewing the client, the nurse notes a discrepancy between the client's verbal and nonverbal communication. What action should the nurse take?
- A. Pay close attention and document the nonverbal messages
- B. Ask the client's husband to interpret the discrepancy
- C. Ignore the nonverbal behavior and focus on the client's verbal messages
- D. Integrate the verbal and nonverbal messages and interpret them as one
Correct Answer: A
Rationale: Noting both verbal and nonverbal cues is crucial to fully understand the client's condition and any potential underlying issues. Verbal communication may not always align with nonverbal cues, which can provide valuable insights into the client's emotional state and concerns. By paying close attention to and documenting the nonverbal messages, the nurse can gather a more comprehensive understanding of the client's situation. Asking the client's husband to interpret the discrepancy may not be appropriate as it could lead to misinterpretation or breach of confidentiality. Ignoring the nonverbal behavior could result in missing essential cues affecting the overall assessment. Integrating both verbal and nonverbal messages helps in forming a holistic view of the client's needs and concerns, enabling better care delivery.
A LVN/LPN is caring for a client with anorexia nervosa. The nurse is monitoring the behavior of the client and understands that a client with anorexia nervosa manages anxiety by:
- A. Engaging in immoral acts
- B. Always reinforcing self-approval
- C. Observing rigid rules and regulations
- D. Having the need always to make the right decision
Correct Answer: C
Rationale: Clients with anorexia nervosa often manage anxiety by adhering strictly to rules and regulations as a way to maintain control. Choice A is incorrect because engaging in immoral acts is not a common coping mechanism for clients with anorexia nervosa. Choice B is incorrect as self-approval is not typically the primary way clients with anorexia nervosa manage anxiety. Choice D is incorrect because while clients with anorexia nervosa may have a need to make the right decision, it is not the primary way they manage their anxiety.
The LPN/LVN is assessing a client who is taking an antipsychotic medication. Which of the following symptoms is uniquely indicative of neuroleptic malignant syndrome (NMS) and requires immediate attention?
- A. Very high temperature
- B. Muscular rigidity
- C. Tremors
- D. Altered consciousness
Correct Answer: A
Rationale: A very high temperature is a hallmark symptom of Neuroleptic Malignant Syndrome (NMS), which is a rare but potentially life-threatening side effect of antipsychotic medications. This symptom is uniquely indicative of NMS and requires immediate medical attention. Muscular rigidity, tremors, and altered consciousness can be seen in other conditions but are not as specifically linked to NMS as a very high temperature.
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.