NCLEX LPN Psychosocial Integrity

The LPN/LVN assists in the care of clients in the pediatric clinic. The mother of a young child asks the nurse why play therapy is offered to children. Which of the following statements by the LPN/LVN is BEST? 1. "Young children have difficulty verbalizing thoughts and emotions." 2. "Children hesitate to confide in anyone but their parents." 3. "Play is an enjoyable form of therapy for children." 4. "Play therapy is helpful in preventing regression."

Strategy: "BEST" indicates that discrimination is required to answer the question. (1) CORRECT—young children are not able to conceptualize their feelings and put them into words; play is how they express themselves; play therapy is the most effective way for the nurse to enter the child's world (2) without a technique to help them communicate, children cannot effective express themselves to anyone; play allows the child to release excessive energy, master situations, resolve conflicts, and relieve anxiety; play is essential to a child's growth and development (3) provides an avenue for children to explore and express thoughts and feelings (4) play therapy provides opportunities for children to develop physical, social, emotional, and cognitive skills

The LPN/LVN identifies which of the following signs and symptoms as MOST representative of the signs/symptoms commonly observed in a client who has recently taken heroin? 1. Constricted pupils, depressed respirations. 2. Dilated pupils, increased respirations. 3. Vomiting and hypotension. 4. Agitation and tachycardia.

Strategy: Think about each answer. (1) CORRECT—client who has recently taken heroin will have the CNS-depressed effects of constricted pupils and slow, shallow breathing (2) signs/symptoms are representative of CNS stimulation (3) nausea and hypertension are symptoms of heroin withdrawal (4) indicate symptoms of stimulant abuse

After a client threatens to commit suicide with a small handgun, the LPN/LVN assists in the admission process by completing the health history data form. The nurse expects to collect which of the following pertinent data? 1. The client is single and has never been married. 2. The client has a low socioeconomic status. 3. The client lives by very strict guidelines. 4. The client is impaired by chronic illness.

Strategy: Think about each answer. (1) lack of family support could be contributing factor but is not significant (2) gender and age more common factors than socioeconomic status (3) clients who attempt suicide are more likely to be impulsive (4) CORRECT because the highest percentage of clients attempting suicide are older adults, 25 to 70% of clients attempting suicide had a long-term physical illness; appears to be important factor in 11 to 50% of the attempts

The LPN/LVN cares for a client after a spontaneous abortion. Because this is the client's fourth spontaneous abortion, she tells the LPN/LVN she believes she is doing something wrong to cause the abortions. Which of the following responses by the LPN/LVN is BEST response? 1. "You feel that you are responsible for the spontaneous abortion." 2. "Perhaps you and your husband should explore adopting a child." 3. "You are a successful professional woman. I am sure you can do this, too." 4. "Would you like medication to help you to relax?"

Strategy: Use therapeutic communication. (1) CORRECT—reflection allows client to verbalize feelings (2) client is grieving, not the best time to suggest alternative goals or solutions (3) not enough evidence to draw this conclusion; correlation of skills is illogical (4) don't ask yes/no questions

Because his wife has been unemployed for 6 months, a client diagnosed with hypertension is worried that they will be unable to pay the rent. Which of the following responses by the LPN/LVN is MOST appropriate? 1. "These things always seem worse than they really are." 2. "Worrying can affect the level of your blood pressure." 3. "You're worried that you won't be able to pay the rent." 4. "I will talk with my supervising nurse."

Strategy: Use therapeutic communication. (1) therapeutic communication does not include "don't worry" responses that give false reassurance and "sidesteps" the client's concerns (2) although this is true to some extent, the nurse should intervene to assist client in dealing with the concern (3) CORRECT—reflects feelings of the client; allows the client to focus on what the client said and the client's feelings (4) may need to communicate information to charge nurse; should first allow the client to verbalize

The LPN/LVN observes one client develop a strong attachment to a second client. This second client repeatedly insults the first. The nurse understands that, for the first client, this is an example of which of the following? 1. Reaction formation. 2. Undoing. 3. Displacement. 4. Introjection.

Strategy: Think about each answer. (1) CORRECT—expressing an attitude that is directly opposite to an unconscious wish or fear (2) an attempt to erase an act, thought, feeling, or desire; apologizing excessively (3) redirection of emotions or feelings to a subject that is more acceptable or less threatening; e.g., yelling at the cat when angry with the instructor (4) one takes into oneself the characteristics of another

The LPN/LVN cares for clients on an acute care inpatient psychiatric unit. The LPN/LVN knows that which of the following clients is MOST likely to successfully commit suicide? 1. A client diagnosed with substance abuse who planned how to commit suicide. 2. A client diagnosed with personality disorder who acted on an impulse to commit suicide. 3. A client diagnosed with depression who took an overdose of Tylenol. 4. A teen-aged girl who notified relatives about a plan to commit suicide.

Strategy: Think about each answer. (1) CORRECT—suicide completers are generally men diagnosed with alcohol or substance abuse who usually plan the act (2) females are more likely to have personality disorders and more likely to attempt suicide on impulse; women attempt suicide more than men but have a low death by suicide rate (3) low lethal method; other low-level methods include slashing one's wrist and inhaling natural gas (4) females are more likely to conduct suicide gestures rather than suicide completion

One day the LPN/LVN overhears the supervisor reprimand the head nurse for not discussing feelings with a client. Shortly thereafter, another client asks for a blanket. The head nurse tells her angrily, "Go get it yourself." This is an example of which defense mechanism? 1. Compensation. 2. Displacement. 3. Conversion. 4. Projection.

Strategy: Think about each answer. (1) an attempt to overcome real or imagined shortcomings (2) CORRECT—head nurse is displacing feelings of anger at the supervisor onto the client, who is less threatening or has less power (3) anxiety is repressed and converted into physical symptoms (4) attributing to others one's own feelings, impulses, thoughts, or wishes

The LPN/LVN cares for substance-abusing clients. The LPN/LVN understands that the nursing care of substance-abusing clients is based on which of the following? 1. The clients have difficulty making decisions. 2. The clients expect too much of themselves. 3. The clients attempt to appease others at all costs. 4. The clients have a limited ability to tolerate anxiety.

Strategy: Think about each answer. (1) limited ability to tolerate anxiety may contribute to some difficulty with decision-making (2) may have feelings of grandiosity, which is the irrational thought that one is entitled to special treatment (3) describes codependent behavior; a codependent focuses on others without regard to personal needs or expectation; a substance-abusing client more likely to be recipient of codependent behaviors via close relationships and family members (4) CORRECT—clients who abuse drugs have a low frustration tolerance and use drugs to escape difficult feelings

A 2-year-old child is brought to the clinic for extensive facial burns. The child's mother states that the burns resulted from the child's running into her lit cigarette. The child is holding onto her mother's skirt and doesn't want to let go to be examined. The BEST reason for the LPN/LVN to suspect this mother is abusing her child includes which of the following? 1. The child's injury is on the face. 2. The mother is upset about the accident. 3. The child is clinging to her mother, refusing to cooperate with the nurse. 4. There is little correlation between the extent of the child's burns and the history of how the child was burned.

Strategy: Think about each answer. (1) location of injury not as important as incompatibility between the history and presenting injury (2) other indications of abuse include conflicting stories about accident or injury, inappropriate response of caregiver such as exaggerated or absent emotional response, refusal to sign for additional tests or necessary treatment (3) warning sign of abuse includes little or no response from the child; excessive or lack of separation anxiety, indiscriminate friendliness to strangers (4) CORRECT—most important criterion is incompatibility between the history and presenting injury

A young adult is admitted to the hospital with a diagnosis of catatonic schizophrenia. When the LPN/LVN places the client's hand over his head, it remains in that position. The LPN/LVN understands that this is a description of which of the following? 1. Conversion hysteria. 2. Waxy flexibility. 3. Dystonic reaction. 4. Neurasthenia.

Strategy: Think about each answer. (1) motor or sensory neurological symptoms with no identifiable physiological cause (2) CORRECT—waxy flexibility is the term used to describe the abnormal posturing of the catatonic; in catatonia, there is a sudden loss of animation and a tendency to remain motionless in a stereotyped position (3) muscle spasms of any muscles of the body (4) unexplained chronic fatigue with nervousness, anxiety, and irritability

The home care LPN/LVN visits a client diagnosed with type 1 diabetes. Although the client's serum glucose continues to be above 250 mg/dL, the client will administer only half of the prescribed dose of insulin. The LPN/LVN identifies this behavior as an example of which of the following? 1. Bargaining. 2. Projection. 3. Denial. 4. Fear.

Strategy: Think about each answer. (1) no evidence that client has made promises to perform one activity in exchange for a specific reward; for example, terminal clients often promise God they will perform certain acts if they are allowed to live (2) attributes personal behaviors to others; is blaming others for his behaviors (3) CORRECT—attempting to shut out reality to reduce the impact of an unpleasant or undesirable experience; client is shutting out the reality of an above-normal serum glucose (4) fear may be driving the behavior, but fear is not a concept commonly associated with response to loss

One morning at a group therapy session, several clients begin to pick on another client because of that client's passive behavior. The LPN/LVN tells the group that the client is a very sensitive person who has problems, and they should stop picking on him. During a postconference with the psychiatric leader-nurse, the LPN/LVN determines that the course of action chosen by the LPN/LVN MOST likely resulted in which of the following? 1. Decreased the client's isolation from the group. 2. Increased the client's insight into the group behavior. 3. Increased the client's isolation from the group. 4. Increased the client's participation in the group.

Strategy: Think about each answer. (1) the nurse should explore the group's feelings and the client's feelings rather than "cutting off" communication; is likely to increase client's isolation from group (2) not likely without exploring and validating the group's feelings; probably should have remained silent and conferred with the lead nurse after the meeting (3) CORRECT—when trying to keep a passive or withdrawn client from being attacked in a group situation, the LPN/LVN should try to point out diplomatically that too much pressure is being applied; in this situation, the LPN/LVN makes the mistake of defending the client, which makes him even more subject to attack; ideally, attention should be diverted or other members mobilized to take the attacked client's position (4) attacking does not encourage participation; could cause the client to identify with the LPN/LVN in a "you and me against the world" process, further decreasing establishment of group membership by the client

When an RN and an LPN/LPN transfer an elderly male client with two chest drainage tubes attached to wall suction, one of the tubes becomes dislodged, resulting in respiratory distress. After the tube is replaced, the client refuses to get out of bed. Which of the following nursing solutions is BEST? 1. Inform the client that the physician will be notified if the client does not get out of bed. 2. Teach the client the consequences of remaining in bed. 3. Offer the client reassurance that the chest tube remains is in place while getting him out of bed. 4. Inform the client that more skilled nurses will assist him.

Strategy: "BEST" indicates that discrimination may be required to answer the question. (1) threats are usually ineffective; does little to reduce client's fears and anxieties (2) more likely to be concerned about risks of dislodgement than vague risks of immobility (3) CORRECT—ask the client to move slowly, and offer the client reassurance that the tube is still in place; may lower client's concerns about dislodgement during ambulation (4) confidence in all staff should be reinforced

A client on a psychiatric unit continually complains that his stomach is missing. After conferring with the charge nurse, the LPN/LVN addresses the client. Which of the following statements by the LPN/LVN is MOST appropriate? 1. "That's not possible because you wouldn't be able to eat anything." 2. "I am here to help you with this problem." 3. "It sounds as if you feel very empty and alone." 4. "This is a common response to depression."

Strategy: "MOST appropriate" indicates discrimination is required to answer the question. (1) do not argue with client or try to convince him that the delusion is not real (2) focus of this response is on the nurse; reflect feeling tone of the delusion (3) CORRECT—depressed clients often have delusions that a body organ is missing or diseased; delusions often reflect feelings of emptiness and loneliness; by making this statement, the nurse helps the client to focus on his feelings rather than on the symptoms or on delusion (4) closed-ended response; doesn't allow the client an opportunity to respond

On the evening before his scheduled lung biopsy, a client says to the LPN/LVN, "Do you think I have cancer?" Which of the following responses by the LPN/LVN is MOST appropriate? 1. "It is not for me to say. You'll know after tomorrow." 2. "You know that you have been taking a chance smoking cigarettes all these years." 3. "Several tests will have to be done to confirm that diagnosis." 4. "You sound worried about what they might find tomorrow."

Strategy: "MOST appropriate" indicates discrimination is required to answer the question. (1) nontherapeutic, closed response does not allow client to verbalize feelings (2) nontherapeutic; blames the client; closed response (3) this response gives information but does not respond to the client's feelings (4) CORRECT—reflects the client's feelings and allows the client to further verbalize

A terminally ill client dies quietly in his sleep. While assisting the charge nurse in managing the family's needs, the LPN/LVN should take which of the following actions? 1. Provide a private place for family members. 2. Explain that the client is in heaven now. 3. Notify the family members individually. 4. Shield the family from viewing the client.

Strategy: Determine the outcome of each answer. Is it desired? (1) CORRECT—providing a private place for family members shows compassion and understanding by the LPN/LVN (2) role of LPN/LVN is to offer comfort without suggesting the outcome of the client's death (3) is time consuming; the family members can notify each other (4) determine what the family desires, then follow their instructions unless is contrary to agency policy; if contrary, should contact charge nurse

The LPN/LVN understands that it is MOST important to utilize which of the following principles when caring for a client immediately after being raped? 1. Focus on the here and now. 2. Ask the client about the needs for crisis counseling. 3. Determine how the rape occurred. 4. Assess how the client has previously responded to trauma.

Strategy: Think about each answer. (1) CORRECT—first action is to assist client to identify her immediate needs and concerns (2) client will be referred for counseling; immediately after rape, LPN/LVN should help client identify immediate needs (3) will aid in prosecuting the perpetrator (4) focus on the client's immediate needs first; exploring how client responded to previous trauma is not helpful now

After a client attempted suicide, the LPN/LVN admitted the client to an inpatient medical unit. The client is LEAST likely to have the following psychiatric or mental disorder? 1. Obsessive-compulsive disorder. 2. Clinical depressions. 3. Schizophrenia. 4. Alcohol abuse.

Strategy: Think about each answer. (1) CORRECT—not likely to have an anxiety disorder (2) more likely to experience clinical depression; 15% of clients who end their lives have depression; bipolar clients are most at risk (3) 40% of clients with schizophrenia have suicidal thoughts; 20 to 40% make unsuccessful attempts (4) 25 to 50% of deaths by suicide are associated with alcohol abuse

During a home visit to observe a client's self-catheterization abilities, the client relates to the LPN/LVN that the client's son has been diagnosed with an antisocial personality disorder. The client says her son has been seeing a therapist and she feels her son is finally going to grow up and assume responsibility. The LPN/LVN identifies that which of the following BEST describes the son's prognosis? 1. The son has a good prognosis because there is no evidence of psychotic behavior. 2. The son's prognosis is doubtful because psychotherapy will cause a regression in behavior. 3. The son's prognosis is good because the problem will be resolved using medication and psychotherapy. 4. The son's prognosis is doubtful because the antisocial client has little, if any, motivation for change.

Strategy: Think about each answer. (1) are often manipulative, untrustworthy, and unreliable (2) tend to act out (3) have poor impulse control and show poor judgment (4) CORRECT—antisocial clients have little motivation for change; usually move from situation to situation in an opportunistic fashion and experience trouble with the law and with other authorities

The LPN/LVN understands that which of the following statements is true regarding anorexia nervosa? 1. Adolescent males are most affected. 2. 5 to 20% of anorexia clients die. 3. Anorexia clients see themselves as emaciated. 4. Anorexia clients are self-indulgent.

Strategy: Think about each answer. (1) common in females 12 to 18 years old (2) CORRECT—anorexia is excessive fear of obesity, dramatic weight loss, distorted body image; 5 to 20% of anorexia clients die from self-imposed starvation and its sequelae, involving fluid-electrolyte imbalance and multiple organ system failure (3) have distorted body image (4) drastically reduce food intake and are preoccupied with foods that cause weight gain

The LPN/LVN cares for a client diagnosed with bipolar disorder during a period of elation. The LPN/LVN follows the nursing care plan and chooses which of the following approaches when caring for the client? 1. Point out the effect the client's behavior has on others. 2. Attempt to distract and redirect the client. 3. Encourage the client to express himself. 4. Provide opportunities for the client to socialize.

Strategy: Think about the outcome of each answer. Is it desired? (1) during manic periods, client has flight of ideas, is disoriented, talks excessively, jokes, dances, sings, is hyperactive; would be unable to deal with the impact of the behaviors on others (2) CORRECT—attempting to distract and redirect the client is the proper course; clients with mania have a tremendous amount of energy, for which they must have an outlet; attempts to confront or limit excessive activities usually lead to an increase in anger and frustration; by redirecting or distracting the client, the LPN/LVN recognizes the client's need for outlets and demonstrates acceptance and understanding of the manic individual's needs (3) during manic phase, client excessively expresses him/herself; important that the staff provide external controls; do not encourage client but help client channel expressions safely (4) during manic phase, important to decrease stimuli; assign to a single room away from activity, limit interactions with people; anticipate situation that will provoke or overstimulate the client

The psychiatric nurse-leader instructs the LPN/LVN to encourage a client with depression to join an activity. Which of the following approaches by the LPN/LVN is BEST? 1. Offer several appealing choices to the client. 2. Tell the client it is part of the doctor's orders. 3. Describe the activity in detail to the client. 4. Invite the client to join in the activity.

Strategy: Think about the outcome of each answer. Is it desired? (1) limit choices, because client feels too inadequate to make choices (2) depressed client fears rejection; would want client to voluntarily join the activities rather than soliciting participation via coercion; therapy is generally designed to help client regain autonomy (3) avoid long explanations because of client's decreased attentiveness and poor concentration (4) CORRECT—good example of how a nurse might lead a client into an activity by telling the client that you would like him/her to join in; it's important to demonstrate caring and acceptance

During an initial home visit to a client diagnosed with a myocardial infarction (MI), the client's wife states that she is having difficulty coping with the client's "obsessive-compulsive" tendencies. Which of the following statements, if made by the client to the LPN/LVN, is consistent with obsessive-compulsive disorder? 1. "I have difficulty making decisions and adjusting to change." 2. "I am sure I am being followed by someone from work." 3. "All of my life I've had problems with being unkempt." 4. "I spend money excessively, which upsets my wife."

Strategy: Think about what the client's words mean. (1) CORRECT—clients with obsessive-compulsive disorder have an extreme need to control and predict outcomes; making decisions and adjusting to changes are anxiety-producing for these clients (2) example of paranoia; exaggerated suspiciousness; characteristic of schizophrenia (3) poor personal hygiene is found in schizophrenics (4) characteristic of bipolar disorder

Which of the following statements, if made by an alcoholic client, indicates to the LPN/LVN that the client has an accurate understanding of the problem? 1. "When I can learn to stop after one drink, I will have my problems beaten." 2. "When my family and work problems go away, I won't need alcohol anymore." 3. "I can't seem to cope with my problems without drinking." 4. "In my business, most people work hard and drink too much."

Strategy: Think about what the client's words mean. (1) denial is a defense mechanism used by clients with addictive symptoms; this statement indicates that the client is still denying the problem (2) statement indicates that the client is still in denial; client lives in a fantasy world in which the time will come when there will be no more problems (3) CORRECT—when the client acknowledges he uses alcohol to cope with problems, he is beginning to break through denial (4) statement does not reflect that client acknowledges using alcohol to deal with problems; client is using rationalization

A depressed mother of two school-age children tells the LPN/LVN that her husband has recently become unemployed. The nurse understands that which of the following is true? 1. The husband's unemployment is a significant potential stressor. 2. This is irrelevant to her depression because her depression is recurrent. 3. Unemployment is considered a developmental crisis. 4. The client is using her husband's unemployment to avoid her own problems.

Strategy: Topic of question is unstated. (1) CORRECT—the loss of financial resources when a client is currently experiencing clinical depression is likely to increase the depth or intensity of the depression and reduce the effectiveness of prescribed interventions (2) any major event can affect depression (3) developmental crises are predictable life events that occur during one's life courtship and marriage, children; unemployment is a situational crises (4) providing the nurse with relevant information about her situation cannot be judged as manipulation; nurse has no evidence to support this conclusion

The LPN/LVN suspects that a child has been abused by her mother and plans to report this to the supervising nurse. After the LPN/LVN tells the mother about the need to do this, the mother bursts into tears. Which of the following responses by the LPN/LVN is BEST? 1. "I can see you are very upset about this." 2. "It's important that I do this to protect the child's health." 3. "Tell me about how things have been going at home." 4. "Toddlers can be very difficult at times."

Strategy: Use therapeutic communication. (1) CORRECT—responds to the mother's behavior; the LPN/LVN is responding to the feeling tone of the mother's behavior (2) because question is about therapeutic communication, important to reflect patient's feelings (3) assessing the situation, which is the second best answer (4) does not reflect patient's feelings

The LPN/LVN cares for a client after a hysterectomy. The LPN/LVN learns the client has recently been widowed, and the client tells the LPN/LVN she especially misses the times she and her husband sat on the front porch at sunset and shared a glass of wine together. Which of the following responses by the LPN/LVN is MOST appropriate? 1. "Your focus should be on recovering from hysterectomy." 2. "That is a happy memory for you." 3. "You should do something else you like during that time of the day." 4. "Do you have a close friend who can share a glass of wine with you?"

Strategy: Use therapeutic communication. (1) should allow client to set priorities; perhaps would recover more effectively if this need is addressed (2) CORRECT—clients often find comfort in prior activities performed with the deceased person; part of denial; provides comfort; reflects the feeling the client is expressing (3) too early to substitute a valued activity associated with the deceased person (4) yes/no question; too early to insert another person into a place normally occupied by the deceased

The LPN/LVN cares for a client experiencing delirium tremens. The client begins shouting, "Bugs are crawling on my skin and up the walls in my room." Which of the following actions by the LPN/LVN is BEST? 1. Provide a quiet, well-lighted area and remain with the client. 2. Provide a quiet room with dim lights and encourage rest. 3. Attempt to distract the client with simple activities. 4. Spray the client with insect repellant.

Strategy: "BEST" indicates discrimination is required to answer the question. (1) CORRECT—a quiet, well-lighted area is essential for a client with delirium tremens; client may experience delusions and hallucinations during withdrawal; nurse can help the client by reassuring her and helping her interpret the environment (2) reassure client and help interpret the environment; dim lights may increase the perceptions of "bugs" (3) appropriate for a manic client; because the visualizations are internal, distraction will not help the client (4) insect repellant validates the hallucination

A woman is admitted to the hospital for a possible mastectomy. The evening before the surgery, her husband appears tense and paces up and down the hall. Which of the following comments by the LPN/LVN to the husband is BEST? 1. "We will do everything we can to help your wife." 2. "This is an upsetting experience for you and your wife." 3. "You will feel relieved once the surgery is over." 4. "I think it might help you if we discussed your wife's surgery."

Strategy: "BEST" indicates that discrimination is required to answer the question. (1) focus of this response is on the nurse/staff; always focus on the client's and/or family's feelings (2) CORRECT—good broad opening, caring comment; acknowledges that the nurse observed the behavior and is reaching out to the husband; invites him to explore matters or feelings with the nurse (3) false reassurance; doesn't respond to husband's nonverbal communication; if the breast is cancerous, the husband may not be relieved (4) might ask or invite him to discuss; he may not want to discuss his feelings or concerns; walking about may be all that he wants or needs

One of the nurse aides on the unit is critical of a client who was admitted after an accidental overdose. The nurse aide says, "All the client does is talk about herself and she does not seem to care how anybody else feels." Which of the following responses by the LPN/LVN to the aide is BEST? 1. "If we can help her realize this, perhaps she can regain her health." 2. "She is probably so nervous and overwhelmed she lacks the ability to care." 3. "Perhaps her family has done a lot to hurt her and bring on these problems." 4. "Being critical of her is not going to help her improve."

Strategy: "BEST" indicates that discrimination is required to answer the question. (1) the underlying problem is anxiety (2) CORRECT—it is important that the nursing staff involved with a client who has personality disorder, or who is a substance abuser, realize that these clients have a grandiose or superficial facade that covers up underlying anxiety and insecurity; it is difficult to give nursing care because these clients provoke anger and irritation; understanding the underlying symptoms and the client's need to manipulate others through fear and lack of trust helps the nurse care for this client (3) very little is known about these problems; the problems are believe to be the result of multiple causes and influences (4) although this is a true statement, explaining to the nurse aid why the client is responding in a certain way is best

A man is informed by his physician that his cancer is inoperable. The LPN/LVN enters the room a short time later and finds the client crying. Which of the following responses by the LPN/LVN is BEST? 1. "This is a sad time for you." 2. "I will leave you alone now." 3. "I'll contact the chaplain." 4. "There is a lot you can accomplish in the time you have left."

Strategy: "BEST" indicates that discrimination may be required to answer the question. (1) CORRECT—the nurse acknowledges that the client is experiencing psychological pain via the threat of the loss of life (2) monitor client's verbal and nonverbal behaviors; may pick up signs that the client wants to be left alone or wants the nurse to remain (3) chaplains perform funerals and last rites, which may further agitate the client; nurse is capable of comforting the client (4) according to the grief process, the client will be in shock; nurse should not attempt to help the client problem-solve

The LPN/LVN cares for a client diagnosed with multiple sclerosis in remission for 5 years. The client suddenly experiences extensive weakness in both legs. The client's spouse is angry, blames the physician, and asks the LPN/LVN to help the family find a new physician "who is more competent." Which of the following responses by the LPN/LVN is BEST? 1. "Your demand for a new physician is upsetting your wife." 2. "Please share with me your specific concerns about your wife's care." 3. "The physician caring for your wife is more than qualified." 4. "Your wife will have to ask me to find a new physician."

Strategy: "BEST" indicates that discrimination may be required to answer the question. (1) is very intense situation; this may help husband calm down but does not address his feelings of disappointment at the return of the signs/symptoms (2) CORRECT—if client has had disease for 5 years, husband is aware of remissions and exacerbations associated with disease; his behaviors are more related to the threats to his wife; opportunity to express his feelings may help him return to more realistic thinking as well as provide the LPN/LVN with data for decision making (3) spouse is not seeking information about physician's ability (4) technically correct; closed statement that does not allow husband to verbalize feelings; more appropriate to encourage husband to express his feelings

The LPN/LVN is asked by the RN to orient a client to the surgical unit. The LPN/LVN observes that the client is pacing, is talking rapidly, and has elevated respirations. Which of the following actions by the LPN/LVN is BEST? 1. Provide an informational booklet. 2. Keep the explanation simple. 3. Delay the orientation until the anxiety has eased. 4. Stress the positive aspects of the unit.

Strategy: "BEST" indicates that discrimination may be required to answer the question. (1) leaving information to be read when anxiety is lower is appropriate, but the nurse should provide a brief verbal orientation (2) CORRECT—client needs some orientation to meet immediate basic needs, such as fluid and elimination; because anxiety reduces comprehension and concentration, only part of what the nurse says will be remembered or retained; keeping explanations simple is the best approach (3) orient the client but do not overwhelm him/her with too much information (4) keep stimulation low when anxiety is high; acknowledge anxious behavior; reflect and clarify; stay with the client

A client diagnosed with inoperable cancer has difficulty walking after chemotherapy. When the LPN/LVN comes to assist the client to the bathroom, the client says, "Leave me alone. You treat me like a child." Which of the following is the BEST interpretation by the LPN/LVN of the client's behavior? 1. The client is frightened about falling. 2. The client is entering a regressive phase. 3. The client wants to maintain independence. 4. The client is angry about the nurse's interference.

Strategy: "BEST" indicates that discrimination may be required to answer the question. (1) may be frightened of falling, but is probably more frightened about losing his independence (2) expressing concern about losing independence would not be considered regressive (3) CORRECT—clients are often frightened by dependence and have difficulty expressing their fear and anger to caretakers; they use projection and displacement to maintain a level of denial until they are ready to move toward acceptance (4) client is rejecting the person offering assistance and the environment, both of which represent the loss of his independence

The LPN/LVN finds a client diagnosed with schizophrenia standing in the dayroom of the psychiatric inpatient unit completely undressed. Which of the following measures by the LPN/LVN is BEST? 1. Cover the client with a towel or sheet and send him back to get dressed. 2. Lead the client back to the client's room and help him get dressed. 3. Ask the client why he seems to need extra attention this morning. 4. Take the client back to the client's room and privately reprimand the client.

Strategy: "BEST" indicates that discrimination may be required to answer the question. (1) this behavior indicates that the client is experiencing a crisis; schizophrenics have difficulty processing information; may not be able to sequence the steps required to get dressed (2) CORRECT—the immediate nursing action is to take the client back to his room and get him dressed; the behavior reflects regression common in schizophrenic clients (3) asking "why" questions is nontherapeutic; this assumes that the client's behavior was purposeful; a nude client in the dayroom is disruptive to the unit (4) important to maintain accepting attitude toward client; a reprimand would not help the client improve; accept regression as a normal part of treatment

To determine their ability to manage prescribed drug therapy, the LPN/LVN schedules weekly home appointments for a group of psychiatric clients. The LPN/LVN learns that several clients recently lost family members. Which of the following clients should the nurse see FIRST? 1. A client diagnosed with schizophrenia. 2. A client diagnosed with anxiety disorder. 3. A client diagnosed with mood disorder. 4. A client diagnosed with cognitive disorder.

Strategy: "FIRST" indicates priority. (1) CORRECT—schizophrenic clients are thought to have a genetic predisposition to stress; stress is more likely to exhaust coping abilities, resulting in display of disequilibrium of the disease process; schizophrenics withdraw from relationships and from the world, have inappropriate or no display of feelings, are suspicious, and are not able to test reality (2) the most common psychiatric disorder; less likely to become significantly disabled than the schizophrenic client, who is likely to require hospitalization; anxiety is the feeling of dread or fear in the absence of an external threat or disproportionate to the nature of the threat (3) most clients do not require hospitalization when therapeutic interventions are initiated to stabilize the client (4) usually have decreased ability to interpret environmental stimuli; less likely to be affected by loss of family member than schizophrenic client is

A man is admitted to the hospital with a diagnosis of paranoid schizophrenia. The LPN/LVN learns the client has not slept for 4 nights. When implementing the client's plan of care, the LPN/LVN should FIRST try to achieve which of the following goals? 1. Increase client's sense of responsibility. 2. Increase client's independence. 3. Promote client's trust. 4. Promote client's rest.

Strategy: "FIRST" indicates priority. (1) have to intervene first with schizophrenic's lack of trust because the schizophrenic views the world as hostile and threatening (2) since client is likely to be fearful, will lack confidence to perform activities independently (3) CORRECT—schizophrenic individuals are highly sensitive to fear of rejection; promoting trust is the nursing approach that should take priority (4) schizophrenic client not likely to rest until he feels safe

When intervening with a client who is in a state of crisis, which of the following statements by the LPN/LVN is MOST appropriate? 1. "Why do you feel so upset in this situation?" 2. "What have you done in the past when you felt this anxious?" 3. "There was no way to prevent this from happening." 4. "It seems as if this situation is very stressful for you."

Strategy: "MOST appropriate" indicates discrimination is required to answer the question. (1) "why" questions imply disapproval (2) CORRECT—helps the client utilize past experience to resolve or reduce current problems (3) LPN/LVN has no evidence to support this conclusion (4) reflective statement; during a crisis situation, more important to determine coping methods used in past

The LPN/LVN assists the supervising nurse to counsel the mother of an infant diagnosed with nonorganic failure to thrive (NFTT). The LVN/LPN notes that the mother appears depressed and is expressing feelings of inadequacy and resentment toward her infant. Which of the following approaches by the LVN/LPN is MOST appropriate? 1. Structure environment so that the mother feels accepted. 2. Suggest that the mother see a family therapist. 3. Tell the mother she is unfit. 4. Recommend to the mother that she attend childcare classes.

Strategy: "MOST appropriate" indicates discrimination is required to answer the question. (1) CORRECT—help parents increase self-esteem by making them feel accepted; LPN/LVN should empathize with parents about the difficulty of child rearing (2) more important to help mother feel accepted (3) judgmental; LPN/LVN should work with the mother to help her improve her parenting skills (4) LPN/LVN should teach parenting skills through example and demonstration; don't lecture to parents

An elderly client diagnosed with organic brain syndrome is hospitalized for dehydration. The LPN/LVN finds the client sitting in the client lounge and notes the client is incontinent of urine. Which of the following actions by the LPN/LVN is MOST appropriate? 1. Tell the client he will have to be catheterized. 2. Tell the client to go to the bathroom and put on clean clothes. 3. Scold the client for soiling himself. 4. Take the client to his room and assist the client to put on clean clothes.

Strategy: "MOST appropriate" indicates discrimination is required to answer the question. (1) dementia is organic condition characterized by impaired memory, abstract thinking, and judgment; LPN/LVN does not have the authority to make this statement; client has already urinated; will not need the procedure now and may not need it the next time; further assessment is needed (2) because client is confused, will require assistance (3) inappropriate; will not achieve professional goals commonly associated with management of the client with this health problem (4) CORRECT—take the client to his room for a change of clothes; conveys warmth and concern by responding kindly, openly, and honestly; do not leave the client alone

The LPN/LVN cares for a client diagnosed with end stage renal disease and obsessive-compulsive disorder in the long-term care facility. The client has difficulty getting to dialysis on time because the client can't decide which clothing to wear. Which of the following actions by the LPN/LVN is MOST appropriate? 1. Place a clock in the client's room so that the client can monitor the time. 2. Allow the client to choose between two sets of clothing. 3. Inform the client she will have 15 minutes to get dressed. 4. Dress the client in the appropriate clothing.

Strategy: "MOST appropriate" indicates discrimination is required to answer the question. (1) obsessive-compulsive disorder is an anxiety disorder; performing compulsive acts temporarily decreases anxiety levels; client is late due to difficulty making a decision; clock may cause increased anxiety (2) CORRECT if client is indecisive, limit the client's choices; if client still unable to make a decision, give client one outfit to wear (3) provide the client with time to dress; this will not help client make a decision (4) encourage client to perform as much of care as possible; give client simple directions

The nurse cares for a client at 36 weeks' gestation with a history of repeated spontaneous abortions. The client is admitted for an emergency appendectomy and is very upset because she is afraid she will lose her baby. Which of the following actions by the LPN/LVN is MOST appropriate? 1. Encourage the client to listen to the fetal heart tone (FHTs). 2. Offer to call a close family member. 3. Offer to call the client's religious leader. 4. Hold the client's hand and offer words of encouragement and comfort

Strategy: "MOST appropriate" indicates that discrimination may be required to answer the question. (1) CORRECT—primary fears are concerns about the health of the fetus; provides direct evidence of the current status of the fetus (2) although having a close family member near during a time of crisis can be helpful, assurance that the fetus is healthy is more likely to lower anxiety level (3) although clients often rely on spiritual guidance from their spiritual leaders during times of crisis, physical evidence of fetal well-being is likely to lower anxiety level; concrete evidence tends to be more effective when clients are anxious (4) probably is the second-best option; touch and comfort by another can be anxiety-relieving; should comfort client while she is listening to the FHTs

The LPN/LVN cares for a client with a tracheostomy. The LPN/LVN notes that the client produces copious amounts of secretions, resulting in frequent airway obstruction. Because the client becomes extremely anxious, which of the following interventions by the nurse is MOST appropriate? 1. Explain the procedure to the client each time. 2. Elevate the head of the bed to 45 degrees. 3. Assure client the nurses will keep the airway patent. 4. Provide an alternative communication method.

Strategy: "MOST appropriate" indicates that discrimination may be required to answer the question. (1) because procedure is performed frequently, would not need teaching each time; delaying procedure to explain could increase client discomfort 2.) head of bed should remain elevated; just elevating the of head of the bed when the airway is obstructed would do little to relieve anxiety (3) CORRECT— frequently reassuring client that nurses will maintain an open airway and suctioning when needed will do more to lower anxiety level than other activities (4) communication is relevant, but assuring client of a patent airway is more likely to lower anxiety; clients correlate open airway with sustaining life

The LPN cares for a client just admitted with a diagnosis of an obsessive-compulsive disorder. The client usually performs 100 sit-ups, along with 30 minutes of aerobic exercise after eating. Because the LPN/LVN needs to administer medications and treat an open wound immediately after the client's meal, which of the following nursing actions is MOST appropriate? 1. Remind the client about the routine unit policies. 2. Explain that performing the activities on time is more important than an exercise routine. 3. Interrupt the client's routine activities, administer the medication, and treat the open wound. 4. Reschedule the medication administration and wound treatment.

Strategy: "MOST appropriate" indicates that discrimination may be required to answer the question. (1) enforcing unit policies could increase client's anxiety level if performance of the ritual is interrupted; obsession is repetitive, uncontrollable thoughts, compulsion is repetitive, uncontrollable acts; accept ritualistic behavior (2) medications likely to be more effective if anxiety-lowering ritual is not interrupted (3) purpose of therapeutic environment is to lower anxiety; interrupting ritual can substantially increase anxiety level (4) CORRECT—premature interruption of rituals can serve to escalate the anxiety; should schedule unit routine another time; structure environment; guide decisions; minimize choices

While an LPN/LVN is teaching family members how to manage tube feeding for an infant, the family receives notice that a 22-year-old son/brother in the military in another country is missing in action. The MOST appropriate intervention by the LPN/LVN for this family is which of the following? 1. Recommend that the family try to go about their normal business. 2. Suggest the family members contact appropriate authorities frequently. 3. Gather the family for a family conference to establish plans for caring for the infant and monitoring new information about missing family member. 4. Discuss how the family will cope if the family member missing in action is not found alive.

Strategy: "MOST appropriate" indicates that discrimination may be required to answer the question. (1) ignores the family's needs (2) keeps family in constant state of extreme anticipation and disappointment; although will be difficult, is best to structure contact times (3) CORRECT—planning conference can prevent family members from becoming exhausted; allows family to build on strengths during time of crisis (4) focus on the here and now; too early to discuss actions to take if the missing family member does not survive

After a client received a renal transplant from a 15-year-old killed in a motorcycle accident, the client expresses feelings of guilt and depression to the LPN/LVN. Which of the following nursing interventions is MOST appropriate? 1. Notify the agency's chaplain. 2. Encourage client to express feelings. 3. Encourage client to express gratitude to donor's family. 4. Inform client the organ would have deteriorated if not used.

Strategy: "MOST appropriate" indicates that discrimination may be required to answer the question. (1) need more information before making referral (2) CORRECT—talking about feelings often reduces the impact of the feelings on client's mental health; failure to respond to client's specific expression often results in suppression of feelings; can use data to determine if referral needs to be done; may simply need to talk about feelings (3) involvement of the donor family is determined first by that family, then by agency policy; further assessment needed to determine if client is ready to face the donor family or if that family is ready to receive the client (4) need further assessment before determining the best intervention

After an abdominal aneurysm is discovered on a client who is planning a 4-week vacation trip around the world, the client begins to sob and expresses feelings of disappointment. Which of the following actions by the LPN/LVN is the MOST appropriate? 1. "Your trip can be rescheduled for this time next year." 2. "An abdominal aneurysm is a very serious problem." 3. "The surgeon is experienced and highly skilled." 4. "You appear disappointed about missing the trip."

Strategy: "MOST appropriate" indicates that discrimination may be required to answer the question. (1) negates client's feelings; is more concerned about the current situation; will take time to adjust (2) not likely to reduce negative impact of disruption in client's life; is still in shock at the loss of scheduled plans; not appropriate at this time (3) does not appear to be concerned about surgeon's skill at this time (4) CORRECT—acknowledges client's pain; shows compassion for client's dilemma; reflective statement allows client to verbalize feelings

The LPN/LVN works in an outpatient psychiatric clinic. Because the clients are nonadherent or noncompliant with the treatment plan, many clients have chronic health problems that are unstable. The LPN/LVN identifies that which of the following is the MOST common reason for the client's nonadherence or noncompliance with the treatment plan? 1. Lack of funds to purchase medication. 2. Failure to acknowledge seriousness of illness. 3. Decreased intensity of signs/symptoms after taking prescribed drugs. 4. Lack of understanding of the treatment plan.

Strategy: "MOST common" indicates discrimination is required to answer the question. (1) because mental illness is often impairing, some clients are unable to work and have no health insurance; clients who can afford to purchase drugs are often noncompliant as well (2) CORRECT—denial of the seriousness of the illness is the most common reason for lack of adherence (3) when signs/symptoms decrease, some clients discontinue prescribed therapy; failure to acknowledge the seriousness of the disease is the most common reason for noncompliance (4) most clients recognize that drug therapy and counseling sessions will decrease the signs/symptoms; more important problem is not acknowledging the seriousness of the illness

Strategy: Determine the outcome of each answer. Is it desired? (1) may not be able to understand written instructions (2) due to confusion, client can't find room; nurse should develop plan that will enable client to find room (3) CORRECT—important to repeat information regarding basic tasks frequently, using simple words; will help the confused client to remember what he is supposed to do (4) has difficulty with memory

Strategy: "MOST important" indicates discrimination is required to answer the question. (1) because sensory stimulation needs to be at minimum, should not agitate but should allow client to lie quietly; position on side until reactive; check vital signs, orient client (2) CORRECT—client who has had electroconvulsive therapy will need reassurance that memory loss is temporary; can be frightening and frustrating aspect of the treatment (3) would be appropriate if client predisposed to fractures because of health alterations such as osteoporosis; muscle relaxants, short-acting anesthesia, and barbiturates administered prior to procedure to prevent fractures (4) no need to communicate this information; client will not remember

The day after the client's admission to the hospital, the LPN/LVN finds the client slumped on the floor with a razor blade in the left hand and blood pouring from the client's right wrist. It is MOST important for the LPN/LVN to take which of the following actions? 1. Ask the client why he is punishing himself this way. 2. Ask the client what precipitated the present crisis. 3. While a nurse assistant applies pressure to the wound, notify the physician. 4. Shout the agency emergency phrase and stay with the client.

Strategy: "MOST important" indicates discrimination is required to answer the question. (1) the primary goal is to manage the current problem: risk of hypovolemia (2) current assessment should focus on immediate needs; because event/s leading to suicidal attempts are complex, diverse, and covert, may take days or weeks for client to fully respond to this question (3) the nurse should remain with client; if the LPN/LVN leaves the nursing assistant in the care of the client, the least trained person is in charge of a situation beyond his/her capabilities (4) CORRECT—best immediate response by the nurse; alerts the staff an emergency exists, which initiates assistance for the client and allows LPN/LVN to remain with client and apply pressure to the wound

After an African American female is diagnosed with breast cancer, it is MOST important for the LPN/LVN to take which of the following actions? 1. Use the same intervention for various emotional states. 2. Assess client's perception of the health care alteration. 3. Inform client that death rates are higher among African Americans. 4. Help client use effective coping skills that she utilized in the past.

Strategy: "MOST important" indicates that discrimination may be required to answer the question. (1) interventions should vary with the emotional states (2) CORRECT—interventions are more effective if they are based on assessment of the client's needs (3) although information is accurate, is likely increase anxiety level (4) assess before implementing; coping tends to be more effective if client utilizes skills that have been successful in the past

While cleansing the wound on a school-aged child who fell from the roof of a storage building, the LPN/LVN overhears the mother and the client interacting. It is MOST important for the LPN/LVN to further assess if the mother makes which of the following statements to the child? 1. "Maybe in the future, you will follow the rules." 2. "You know, of course, this means no dinner tonight." 3. "Why did you climb up there when I told you not to?" 4. "It appears that your injury isn't serious."

Strategy: "MOST important" indicates that discrimination may be required to answer the question. (1) parents are sometimes punitive when children are suffering the consequences of their behavior; they sometimes do this to reassure themselves that they were not at fault (2) CORRECT—indicative of improper disciplinary action; indicates also that this has been utilized before; supervising nurse needs to be involved (3) individuals often explore why others make certain choices; may need teaching about growth and development for this age group (4) reflects caring and compassion

Following the birth of a 7-lb, 2-oz baby girl, the mother declines to participate in the newborn's care, stating, "I am tired, I have a headache and am nauseous." Before discharge occurs, it is MOST important for the LPN/LVN to take which of the following actions? 1. Premedicate client before care is scheduled. 2. Further assess how the mother is feeling. 3. Discuss newborn care with the mother. 4. Conference with psychiatric nurse with regard to risks to newborn.

Strategy: "MOST important" indicates that discrimination may be required to answer the question. (1) signs/symptoms are not commonly associated with postpartum; indicates another process is operating (2) CORRECT—should further assess the mother to determine the cause of symptoms; can be physical causes or psychological causes; rule out physical causes first (3) could result in guilt feelings which could further "bury" the mother's needs (4) because hospital stay is brief; risks to newborn should be explored; first determine why client is feeling the way she is feeling

A young adult client is hospitalized with thrombophlebitis. The LPN/LVN learns the client has a 3-year-old daughter. The LPN/LVN identifies that which of the following factors is MOST likely to be the client's major concern during the illness? 1. Who will care for the client's 3-year-old daughter. 2. The restriction of the client's independence. 3. The loss of income due to illness. 4. The perception of illness as failure.

Strategy: "MOST likely" indicates discrimination is required to answer the question. (1) CORRECT—while client is hospitalized, unable to maintain the parenting role; may be concerned about who will care for the child during hospitalization and whether or not the child will receive the best possible care (2) because strict bedrest is the primary intervention, the client may be concerned about the lack of independence but is more likely to be more concerned about current child care needs (3) absence from work is likely to be extensive, but client will probably tend to other problems after the care of the 3-year-old is managed (4) no information given to support this answer

The LPN/LVN is a member of the team that cares for clients in an outpatient clinic. A client relates to the LPN/LVN, "I travel only by train because I am terrified of flying." The LPN/LVN understands that the client with a phobia is MOST likely to respond to which of the following? 1. Major tranquilizers. 2. Insight-oriented therapy. 3. Crisis intervention. 4. Systemic desensitization.

Strategy: "MOST likely" indicates discrimination is required to answer the question. (1) antipsychotic medications used to treat symptoms of being out of touch with reality (2) this type of therapy involves the family unit; clients with phobias respond best to desensitization (3) crisis intervention is aimed at helping the client manage responses to a situational or developmental event that results in a temporary state of disequilibrium; client is guided to develop the new skills needed to manage the outcomes (4) CORRECT—enables client to encounter the phobic object gradually while using relaxation techniques; self-esteem is improved when the client is finally able to conquer the phobic situation

After the mother of an obese 17-year-old client is informed that her daughter is at 40 weeks' gestation and requires an emergency C-section, the mother exhibits behaviors indicative of a panic attack. To explain preoperative procedures to the mother, which of the following approaches by the LPN/LVN will be MOST successful? 1. Use short, simple sentences. 2. Explain the procedure in detail. 3. Provide time alone. 4. Display parenting-like behaviors.

Strategy: "MOST successful" indicates that discrimination may be required to answer the question. (1) CORRECT—panic-level anxiety is demonstrated by an inability to see and hear, inability to function; will have difficulty focusing; communication should be short, simple, necessary, and to the point (2) perception field is already overwhelmed; detailed information cannot be received, interpreted, applied, or retained (3) should remain with the mother until anxiety is reduced (4) need to use firm, professional approach; will need emotional support; parenting not appropriate for age

The day after a bone-marrow aspiration to determine the reason for an excessive WBC level, an LPN/LVN notices the client is restless and appears very anxious. Which of the following nursing actions should the LPN/LVN perform NEXT? 1. Offer to provide reading materials. 2. Report observations to supervising nurse. 3. Allow the client to express feelings about the bone-marrow aspiration. 4. Administer PRN anti-anxiety medication.

Strategy: "NEXT" indicates priority. (1) activity does not match needs; would require sitting still as well as some measure of close concentration; should assess how client usually relieves anxiety (2) need further assessment before making referral (3) CORRECT—should discuss feelings about the test; on the basis of the client's response, can follow up with more focused question (4) need further assessment before determining medication is the best intervention

The lead psychiatric nurse informs the LPN/LVN about a teaching session with the spouse of a client on how to cope with the client's anxiety. The LPN/LVN determines that teaching is successful if the spouse makes which of the following statements? 1. "Anxiety is a conscious means of resolving conflict." 2. "Anxiety represents an unconscious or internal conflict of needs." 3. "It is important to confront my husband when he is anxious." 4. "Anxiety is increased by using defense mechanisms."

Strategy: "Teaching is successful" indicates correct information. (1) anxiety is not supported by a conscious effort; anxiety has no specific focus; clients usually cannot state specifically why they are nervous (2) CORRECT—the root of anxiety is the conflict between expressing unacceptable impulses and the need to hold onto social approval; anxiety can be precipitated by threats to the self-concept or self-esteem (3) do not confront client; be patient and accepting; allow the person with the disorder to set the pace for recovery (4) defense mechanisms are a way for the client to cope with the anxiety; do not enable avoidance

When assisting in management of the nursing care of a client with peptic ulcer disease (PUD), the LPN/LVN identifies that which of the following nursing measures is indicated? 1. Identify stress factors in the person's environment. 2. Avoid giving the person choices to make. 3. Encourage the person to become angry. 4. Avoid discussing the person's symptoms.

Strategy: Determine the outcome of each answer. Is it desired? (1) CORRECT—important to identify elements in the client's environment that contribute to stress when caring for a client with a psychophysiological disorder; work habits and personal habits, such as smoking and drinking, must be evaluated to have the client adopt a less stressful lifestyle (2) is appropriate to limit choices for clients with impaired levels of anxiety; otherwise, the nurse should help the client make decisions among the choices available (3) encourage client to verbalize whatever feelings exist; not necessarily anger (4) proper management of the health alteration requires that the signs/symptoms need to be thoroughly discussed

The LPN/LVN assists in the care of a client with a terminal illness. It is MOST important for the LPN/LVN to take which of the following actions? 1. Reassure the client that he is not alone. 2. Attempt to promote hope in the client. 3. Be helpful to the client at all times 4. Discourage denial in the client.

Strategy: Determine the outcome of each answer. Is it desired? (1) CORRECT—this is very important in the care of the dying client; fear of the unknown is frightening to dying clients; may become frightened of procedures and anything that reminds them that they will eventually die; need the continual reassurance that staff and family are available at all times and will be there for them (2) don't give client false reassurance; would need to consult with lead nurse to gain insight into the best approach to helping client have hope for the least amount of discomfort possible as the disease progresses (3) more important to convey that client is not alone; since nursing has boundaries and limitations, would be times when nurse could not be helpful (4) denial protects client from overwhelming anxiety; would need to consult with RN about such complex matters; client needs to be free to exercise any defense mechanism that would bring comfort without causing harm

The LPN/LVN assists with care of clients on the psychiatric unit. Based on the nursing care plan, it is MOST important for the LPN/LVN to take which of the following actions when intervening with a client who is demonstrating violent behavior? 1. Tell the client that he has no control over his behavior. 2. Point out that the client is making others anxious. 3. Remain calm and state that the LPN/LVN notices the behavior. 4. Touch the client gently and reassure him.

Strategy: Determine the outcome of each answer. Is it desired? (1) acknowledge signs of impending violence without disagreeing or confronting the client (2) decrease stimuli; remove threatening objects or people (3) CORRECT—acknowledging the client's behavior encourages communication of need; calm behavior can encourage client to relax (4) avoid body contact; use nonthreatening body language, arms to side, palms outward, keep distance, avoid blocking exit

While a dressing is being changed on a left lower leg amputation, the client informs the LPN/LVN he is unable to shop for groceries because he does not know how to operate the motorized shopping carts. Which of the following responses by the LPN/LVN is BEST? 1. Ask client to have family members help with grocery shopping. 2. Contact supervisor about having home health aid shop for groceries. 3. Contact store manager about possible training for use of the carts. 4. Contact supervisor about having physical therapist for proper training.

Strategy: Determine the outcome of each answer. Is it desired? (1) appropriate if client were not physically or mentally able to perform tasks; client has identified a specific problem (2) need to investigate client's interest before recommending; independence is primary goal (3) store manager may or may not have the needed skills (4) CORRECT—is safest method and promotes highest degree of independence

The spouse of a phobic client is troubled by his wife's sudden fear of elevators. He asks the LPN/LVN, "What should I do when she gets frightened?" After conferring with the nurse, the LPN/LVN encourages the husband to take which of the following actions? 1. Ride with his wife on the elevator. 2. Encourage his wife to get on the elevator. 3. Allow his wife to avoid the elevator. 4. Encourage his wife to discuss her fears.

Strategy: Determine the outcome of each answer. Is it desired? (1) better to acknowledge client's distress and concerns; client is attempting to make the anxiety tolerable in the best way possible (2) do not attempt to remove the defense mechanism at any time (3) CORRECT—well-meaning friends and family often encourage a client to encounter the feared object; this only increases apprehension and anger on the part of the client; by allowing his wife to avoid the elevator, her husband accepts her position while therapy is under way (4) more important that the client be able to avoid the elevator; acknowledge anxious behavior; reflect and clarify; always remain with client

The LPN/LVN interacts with a client diagnosed with obsessive-compulsive disorder. Because of a hand washing ritual, the client has difficulty getting to meals on time. In following the plan of care, it is MOST important for the LPN/LVN to implement which of the following interventions? 1. Permit client to eat in the room. 2. Allow the client to be late for meals. 3. Notify the client 15 minutes before mealtime. 4. Instruct the client to discuss the matter with the doctor.

Strategy: Determine the outcome of each answer. Is it desired? (1) goal is to help client manage daily activities while dealing with need for excessive hand washing (2) does not give the client direction about how to deal with the hand washing ritual (3) CORRECT—temporarily allows time to perform the anxiety-relieving ritual; relieves the client from any sense of pressure (4) referrals are outside the LPN/LVN role; if LPN/LVN perceives that referral may be needed, should discuss with charge nurse; there is no direct line of authority from the LPN/LVN to the physician

A confused client constantly tells the LPN/LVN he's lost and asks where his room is. It is MOST important for the LPN/LVN to take which of the following actions? 1. Provide written instruction concerning the unit floor plan. 2. Encourage the client to look for his room. 3. Repeat basic information to the client frequently. 4. Reinforce that he has found his room before.

Strategy: Determine the outcome of each answer. Is it desired? (1) may not be able to understand written instructions (2) due to confusion, client can't find room; nurse should develop plan that will enable client to find room (3) CORRECT—important to repeat information regarding basic tasks frequently, using simple words; will help the confused client to remember what he is supposed to do (4) has difficulty with memory

On the third postoperative day, a client with a left mastectomy incision continues to request analgesia for incisional pain q 3-4 hours. The LPN/LVN observes the incision and determines that normal healing is occurring. Which of the following responses by the LPN/LVN is BEST? 1. Palpate the wound area to express trapped drainage. 2. Request referral for a psychiatric consultant. 3. Provide the client opportunity to express feelings about the surgery. 4. Inform client she does not need analgesia.

Strategy: Determine the outcome of each answer. Is it desired? (1) normally performed by the surgeon (2) not enough information to make this judgment; should continue to talk with the client and then the LPN/LVN will consult with the supervising nurse (3) CORRECT—with physical impairments eliminated, may be using analgesia to postpone dealing with emotional response to surgical procedure as well as a life-threatening health alteration (4) not the best response; indicates may be using analgesia to consciously or unconsciously to deny or escape the situation; further assessment is needed

Strategy: Topic of question is unstated. (1) CORRECT—the loss of financial resources when a client is currently experiencing clinical depression is likely to increase the depth or intensity of the depression and reduce the effectiveness of prescribed interventions (2) any major event can affect depression (3) developmental crises are predictable life events that occur during one's life courtship and marriage, children; unemployment is a situational crises (4) providing the nurse with relevant information about her situation cannot be judged as manipulation; nurse has no evidence to support this conclusion

Strategy: Determine the outcome of each answer. Is it desired? (1) situation is potentially volatile; need to defuse to some degree before leaving room (2) CORRECT—address the dominant member to restore control; the more passive client will probably remain quiet while the nurse tries to diffuse the anger of the aggressive client (3) contracting is appropriate for client, but first want to de-escalate the situation (4) punitive response; time-out is an appropriate intervention; this comment by the nurse will only escalate the situation

The LPN/LVN interacts with a client diagnosed with depression. The LPN/LVN expects the client to express which of the following thoughts? 1. "I'm embarrassed that everyone has to take care of me." 2. "Once my depression is over, I'll be able to get on with my life." 3. "I like being taken care of from time to time." 4. "I'm glad that I came for help in time.

Strategy: Think about each answer. (1) CORRECT depressed clients usually have feelings of guilt and unworthiness, and have difficulty accepting help from others because of these feelings; although depressed clients may be dependent and demanding, they often feel unworthy of the attention they receive and are embarrassed by their feelings of helplessness (2) clients with depression have a sense of doom or failure; have difficulty being able to plan for the future (3) may be dependent or demanding but often feel unworthy of the attention and are embarrassed by feelings of helplessness (4) an introspective statement that indicates the client is feeling better

The LPN/LVN cares for clients in the long-term care facility. The LPN/LVN assists in the admission of a client diagnosed with type 1 diabetes and diabetic neuropathy. The client's daughter states that her mother has a history of depression. The LPN/LVN expects to gather which of the following data? 1. The client's daughter states her mother has decreased attention span and concentration. 2. The client makes unreasonable requests for time, attention, and favors. 3. The client threatens to do harm to the staff. 4. The client states she is in charge of life.

Strategy: Think about each answer. (1) CORRECT problems with depression occur among people with medical disorders; indications include changes in self-esteem and self-confidence, lack of energy, unkempt appearance, poor appetite (2) more likely to occur with client who is manipulative (3) depression causes slowed speech, slowed thought processes, and slowed motor activity; be alert for self-destructive behaviors (4) depression causes feelings of helplessness and hopelessness

The LPN/LVN makes a home visit to verify whether a 24-year-old female client recently diagnosed with schizophrenia is taking her medications properly. Because the client's husband is very distraught about the diagnosis, he asks the nurse about the disease. The BEST response by the LPN/LVN includes which of the following? 1. "Schizophrenia is associated with an imbalance of chemicals in the brain." 2. "Schizophrenia is generally associated with drug and alcohol abuse." 3. "Schizophrenia may be related to a lack of oxygen during delivery." 4. "Schizophrenia is often associated with incest and child abuse."

Strategy: Think about each answer. (1) CORRECT—drugs that decrease the signs/symptoms of schizophrenia affect the functions of neurotransmitters, such as serotonin, dopamine, and glutamate (2) drug and alcohol abuse are associated more with depression (3) lack of oxygen during delivery generally associated with cerebral palsy (4) incest and child abuse more common in suicide-prone individuals

The LPN/LVN assists in management of the care of a client diagnosed with antisocial personality disorder. Which of the following statements, if made by the client to the nurse, MOST indicates an improvement in the client's condition? 1. "I get into trouble because I don't think before I act." 2. "My parents have difficulty accepting my independence." 3. "I've spent very little time actually enjoying life." 4. "It's sad that others don't recognize my potential."

Strategy: Think about each answer. (1) CORRECT—introspective remark that shows that the client is beginning to realize that she acts out of anxiety or tension without realizing the consequences of her actions (2) clients with antisocial personality disorder see themselves as being free and unconfined by persons, obligations, or routines; untrustworthy and unreliable (3) appear charming, intellectual, and smooth-talking (4) statement indicates denial of behavior; clients with antisocial personality disorder are immature and irresponsible

A 29-year-old woman who was told by her doctor that she cannot have children subsequently forms a close attachment to her niece and nephew. The LPN/LVN understands that this is an example of which of the following defense mechanisms? 1. Sublimation. 2. Projection. 3. Undoing. 4. Rationalization.

Strategy: Think about each answer. (1) CORRECT—is sublimating her desire to be a mother through a close attachment to her niece and nephew; by using sublimation, she can satisfy some of her unmet maternal instincts; will need to work through the issues of loss and the mourning process that usually accompany infertility (2) is not projecting her feelings of loss on others (3) client would pretend they were her children or communicate to others that she actually gave birth or planned to (4) an individual makes excuses for his/her behavior or attempts to justify unacceptable behaviors; developing close attachment to niece and nephew is not considered unacceptable unless interferes with safety and development of the children

The LPN/LVN works on an acute care psychiatric unit. The LPN/LVN understands that in a psychiatric inpatient setting, milieu therapy is BEST understood as which of the following? 1. Milieu therapy provides a therapeutic physical and social environment. 2. Milieu therapy manipulates the environment so the client feels at home. 3. Milieu therapy establishes therapeutic communication with numerous staff members. 4. Milieu therapy sets limits on behavior.

Strategy: Think about each answer. (1) CORRECT—milieu therapy provides a therapeutic social, cultural, and physical environment in which all aspects are utilized as instruments of growth to the client's benefit (2) want to establish environment in which client feels safe and is able to work through issues (3) not the purpose of milieu therapy (4) not the purpose of milieu therapy

A 43-year-old housewife who had a hysterectomy 6 months ago suddenly develops an intense fear of elevators. When she approaches the elevator in her apartment building, she becomes panicky and cannot enter the elevator. The LPN/LVN understands that this client's fear of elevators is due to which of the following? 1. A projection of anxiety onto a neutral object. 2. A common postoperative phenomenon in females. 3. An attempt to undo her traumatic hospital experience. 4. A conversion reaction to emotional stress.

Strategy: Think about each answer. (1) CORRECT—the client has developed a phobia in which anxiety is projected onto a neutral object, the elevator; the client has not worked through her response to surgery; avoidance behavior symbolizes her anxiety (2) is not a common postoperative phenomenon in women after a hysterectomy (3) undoing would be represented more by behaviors such as talking about needing the surgery, pretending to be pregnant, having menstrual cramps, or wearing a sanitary napkin (4) ) if this were the correct answer, client would exhibit loss of function of a body part

An LPN/LVN provides care for a client who is worried that a tumor removed from the pancreas may be cancerous. The LPN/LVN identifies which of the following behaviors as MOST commonly associated with anxiety? 1. Insomnia. 2. Anger. 3. Fear. 4. Aggression.

Strategy: Think about each answer. (1) anxiety can interfere with sleep, but inability to sleep is not a behavior most commonly associated with anxiety (2) CORRECT— somatizing, anger, and withdrawal are commonly associated with anxiety; all serve to reduce the emotion (3) fear generally coexists with anxiety, but does not lower the intensity of the emotion (4) can reduce anxiety, but is not most commonly associated with the emotion; most individuals do not exhibit aggression when they are anxious

A student nurse in a practical nursing program fails an examination and accuses the psychiatric instructor of being an unfit teacher and causing the failure. The LPN/LVN recognizes that this is an example of which of the following? 1. Conversion. 2. Acting out. 3. Compensation. 4. Projection.

Strategy: Think about each answer. (1) anxiety is repressed and converted to a physical symptom (2) acting-out behavior is impulsive, pathological, and antisocial; student has poor coping when anxious or depressed (3) an attempt to overcome real or imagined shortcomings (4) CORRECT unable to accept her sense of failure and resulting poor self-esteem, the student projects the failure onto the instructor, thereby saving face but coping ineffectively

The LPN/LVN assists in the care of clients in a mental health clinic. A client with depression joins an ongoing therapy group. The LPN/LVN understands that the primary goal of group therapy for a client diagnosed with depression includes which of the following? 1. Introduce the client to other clients. 2. Communicate acceptance to the client. 3. Encourage the client's decision-making. 4. Increase the client's sense of responsibility.

Strategy: Think about each answer. (1) appropriate to introduce client to others when client is ready; assist client to decrease social withdrawal; sit with client during long quiet times; client fears rejection (2) CORRECT—because depressed clients have experienced self-rejection and a loss of self-worth, the most important thing to communicate initially is a sense of acceptance; acceptance by others paves the way for self-acceptance (3) decision-making is preceded by self-acceptance and increased self-esteem (4) successfully completing tasks will relieve guilt and increase self-esteem, but is not the goal of group therapy

The LPN/LVN cares for a client diagnosed with Alzheimer's disease. The client's adult child says to the LPN/LVN, "Why can my mom not communicate appropriately?" The LPN/LVN's response should be based on which of the following? 1. Alzheimer's is caused by hardening of the arteries due to increased plaques associated with cholesterol. 2. Alzheimer's causes decreased levels of dopamine. 3. Alzheimer's causes swelling of the brain, resulting in increased pressure and cell death. 4. Alzheimer's is a collection of a protein resulting in the breakdown of transmission of information.

Strategy: Think about each answer. (1) associated with senility (2) associated more with Parkinson's disease (3) associated with head trauma or stroke (4) CORRECT buildup of amyloid protein secondary to decreased production or availability of acetylcholine results in decreased communication among neural circuits

A man diagnosed with bipolar disorder is hospitalized in the elation phase of the illness. The client says to the LPN/LVN, "Even though I don't have a job, I just bought myself a home computer and a large screen TV for my family." Which of the following interpretations by the LPN/LVN is MOST accurate? 1. The signs/symptoms are related to substance abuse. 2. The client has an increased need to manipulate electronic devices. 3. The client is goal-directed and is steadfast in meeting the goals. 4. The client has a mood disturbance and his judgment is poor at this time.

Strategy: Think about each answer. (1) bipolar disorder is an affective disorder characterized by delusions of grandeur, flight of ideas, and lack of inhibitions; behavior not associated with substance abuse (2) unrestrained buying sprees are common; not necessarily related to any particular type of item (3) in full-blown mania, clients are unable to sit still and are hyperactive; unable to establish goals and execute a plan to achieve the goals (4) CORRECT—person in a manic state may have delusions of grandeur and/or an exalted opinion of himself and his abilities; can be manipulative, testing, and demanding due to poor self-esteem

The LPN/LVN prepares a client for surgery to remove a malignant tumor from the large intestine. The client appears calm and relaxed. The client remarks to the nurse, "My health is fine. My physician has always been a pessimist." The LPN/LVN identifies that this statement is an example of which of the following defense mechanisms? 1. Sublimation. 2. Denial. 3. Displacement. 4. Intellectualization.

Strategy: Think about each answer. (1) channeling unacceptable impulses or behaviors into socially acceptable behaviors (2) CORRECT—denying the extent of his illness; at this time, denial protects him from overwhelming anxiety (3) redirecting emotions or feelings to a subject that is more acceptable or less threatening (4) thinking is disconnected from feelings; deal with situations on a cognitive level and ignore the emotional aspect

After experiencing delirium tremens, the client tells the LPN/LVN, "I like to drink more than the average person, but I hold my liquor well and can stop when I put my mind to it." The LPN/LVN identifies that the client is using which of the following defense mechanisms? 1. Suppression. 2. Repression. 3. Denial. 4. Reaction formation.

Strategy: Think about each answer. (1) conscious decision to not deal with something perceived to be unpleasant; can be used in a healthy way or in an unhealthy way (2) unable to remember traumatic events; unacceptable thoughts are kept from awareness; first line of psychological defense against anxiety (3) CORRECT—unconscious process in which there is a refusal to admit that certain feelings or situations exist; by denying that he has a drinking problem, the client can avoid the anxiety that surfaces with the realization that he is unable to help himself (4) express an attitude that is opposite to unconscious wish; considered overcompensation

A client diagnosed with obsessive-compulsive disorder tells the LPN/LVN that he is afraid about contracting AIDS. The client spends much of the day washing his hands and spraying disinfectant in the room. The LPN/LVN understands that the client's hand-washing behavior represents which of the following? 1. A drive that needs to be denied. 2. A dissociative response to trauma. 3. A hidden wish to become ill and disabled. 4. A symbolic expression of conflict and guilt.

Strategy: Think about each answer. (1) drive is an internal or external stimulus that motivates the individual; obsession is repetitive, uncontrollable thought; compulsion is repetitive, uncontrollable action (2) dissociation disconnects one part of memory from another; client is associating cleanliness with prevention of AIDS (3) hypochondriasis is being overly concerned about one's health (4) CORRECT—repetitive behaviors are attempts to control anxiety; clients have a need to control themselves, others, or their environments

While volunteering in a homeless shelter, a LPN/LVN notices that another volunteer develops overly close relationships with the older women in the shelter. During conversation, the volunteer relates to the LPN/LVN that the volunteer would not let her sick mother come live with her before the mother's death. The LPN/LVN understands that the volunteer is using which of the following defense mechanisms? 1. Repression. 2. Undoing. 3. Compensation. 4. Denial.

Strategy: Think about each answer. (1) if volunteer were using this defense mechanism, the topic of the mother would be discussed as if she were still alive or the mother had been allowed to live with the daughter (2) CORRECT—"undoing" an action is an attempt by the volunteer to erase the action; this may be expressed by excessive apologies (3) an attempt to overcome real or imagined shortcomings by giving valid reason for refusing to allow mother to move in (4) failure to acknowledge an intolerable thought, feeling, or experience, or to acknowledge reality; would avoid discussing the situation

After a motor vehicle accident (MVA), a 17-year-old female client has a permanent colostomy. The client's mother verbalizes to the LPN/LVN that her past relationship with her daughter was difficult, but the relationship has improved since the accident. Because of the improved relationship, the client's mother tells the LPN/LVN that the accident was "a blessing in disguise." The LPN/LVN knows the mother's behavior is MOST representative of which of the following? 1. Depression. 2. Anger. 3. Denial. 4. Rationalization.

Strategy: Think about each answer. (1) is exhibited more via withdrawal or somatizing (2) exhibited more in sarcasm, overreacting to minor incidents, verbal attacks, and irritability (3) mother is acknowledging accident and colostomy (4) CORRECT—is plausible method of helping one deal with disappointment; helps avoid disapproval; helps soften the impact of loss related to illness

The LPN/LVN assists in the care of clients in an inpatient psychiatric unit. The charge nurse is leading an adolescent social/support group to discuss the difficulties of growing up in the United States. The LPN/LVN understands that the primary benefit of this type of group is based on which of the following? 1. The group's ability to evaluate their behavior. 2. The phase of the group's interaction. 3. The leader's skill in promoting progress. 4. The group members' sense of belonging.

Strategy: Think about each answer. (1) most age-related groups focus on issues that are specific to their developmental age; may be supportive or educational (2) group members can benefit during all stages of group development; for example, members may benefit from helping establish group organization and boundary setting, participating in establishment of norms, and setting goals after the group terminates; this is not unique to adolescents (3) group leader in most groups initiates the group, provides continuity, and facilitates cohesiveness; is not unique to adolescents (4) CORRECT—adolescents are strongly influenced by their peers; the therapeutic benefit of this group can be enhanced through a sense of belonging in which they can establish norms for behavior and work through shared problems

A small girl is hospitalized with a major burn that occurred in a car accident with her mother. Her mother leaves the hospital room, saying, "I just can't stand looking at her burns; they make me feel sick." Which of the following is the MOST accurate interpretation by the LPN/LVN of the mother's behavior? 1. The mother is having doubts about her ability to help her daughter. 2. The mother is showing resentment about the child's need for intensive care. 3. The mother is experiencing guilt from being a neglectful mother. 4. The mother is reacting to her daughter's changed body image.

Strategy: Think about each answer. (1) no information given to support this answer (2) these words do not express resentment (3) in order to select this answer, you assume that the mother is feeling guilt; she says that she has difficulty looking at the wounds (4) CORRECT—common reaction; nurse should provide support to the mother

The LPN/LVN cares for a client diagnosed with clinical depression. The LPN/LVN teaches the client about the prescribed medications. It is MOST important for the LPN/LVN to include which of the following statements about the client's antidepressant medication? 1. "Antidepressants reverse the sequence of the sleep cycle." 2. "Antidepressants affect the function of norepinephrine and serotonin." 3. "Antidepressants promote the actions of estrogen and testosterone." 4. "Antidepressants affect the brain's ability to metabolize glucose."

Strategy: Think about each answer. (1) one side effect of the drug is drowsiness; can induce the sleep cycle (2) CORRECT—it is well documented that these neurotransmitters are directly related to mood disorders; drug causes balancing of the chemicals, resulting in mood elevation (3) although fluctuation of estrogen levels can affect the mood, drugs are not known to have significant impact on gender hormone levels or functions (4) brain glucose levels are known to have an influence on clients with schizophrenia; drugs are not known to have a clinical influence on the brain's use of glucose

After several months of isolation, a stage performer agrees to seek treatment for a panic disorder. After the laboratory and diagnostic test results are brought to the unit, the LPN/LVN notifies the health care provider that which of the following verifies the preliminary diagnosis of an anxiety disorder? 1. The client exhibits increased serum blood urea nitrogen levels. 2. The client exhibits reduced serum calcium levels and decreased thalamus function. 3. The client exhibits a decreased response to stimulants such as caffeine. 4. MRI (magnetic resonance imaging) shows atrophy of the client's frontal lobe and temporal lobe.

Strategy: Think about each answer. (1) renal damage is not a common complication of panic disorders (2) could indicate renal damage as well; decreased thalamus function is not symptomatic of panic disorders (3) tend to exhibit excessive response to caffeine (4) CORRECT both lobes tend to exhibit decreased size in clients with panic disorders

The LPN/LVN recognizes that the PRIMARY problem for a client with a diagnosis of schizophrenia includes which of the following? 1. A split personality. 2. Compulsive behavior patterns. 3. Difficulty in forming relationships. 4. Acting-out behavior patterns.

Strategy: Think about each answer. (1) split between the thinking and the emotional aspects of the personality (2) seen in impulse-control disorders, which include an irrational drive to act impulsively; schizophrenic clients would have difficulty carrying out some the complex activities often performed by clients with impulse control disorders (3) CORRECT—difficulty in forming relationships with a marked inability to trust others is the main problem with schizophrenia (4) may exhibit acting-out behaviors such as anger and hostility toward those in the current environment, but is not the primary problem

A client who has been drinking heavily for the past five years is admitted to the hospital in alcohol withdrawal. The LPN/LVN should observe for which of the following symptoms? 1. Yawning, lacrimation, muscle cramps. 2. Memory loss, drowsiness, diminished reflexes. 3. Ataxia, nystagmus, postural hypotension. 4. Increased pulse, tremors, anxiety.

Strategy: Think about each answer. (1) symptoms of narcotic withdrawal (2) symptoms of potential alcohol intoxication (3) ataxia and bradycardia could indicate alcohol intoxication (4) CORRECT—symptoms occur in a client physiologically dependent on alcohol; abrupt withdrawal causes tremors, insomnia, anorexia, and alcoholic hallucinations; nursing care includes administering sedation, monitoring vital signs, seizure precautions; provide quiet, well-lighted room, don't leave hallucinating, confused client alone

The LPN/LVN understands that according to Maslow's hierarchy, which of the following needs are MOST basic to any client's health maintenance plan? 1. Love and belonging. 2. Esteem and recognition. 3. Safety and security. 4. Self-actualization.

Strategy: Think about each answer. (1) the basic needs have to be met first; the most basic needs are the physiological needs (oxygen, food, water, etc.); if the basic needs are not met, the person will die; working on love and belonging occurs after the basic needs are met (2) person has positive self-esteem and the recognition of others; this level occurs after mastering love and belonging (3) CORRECT—the person establishes stability and consistency in life; is mostly psychological; if person does not feel safe, there is no energy for other pursuits (4) highest level; person becomes everything that s/he is capable of becoming

The nurse and the LPN/LVN prepare to lead a group session for clients with a dependence on alcohol. The LPN/LVN knows that the primary reason an alcoholic client drinks is because of which of the following? 1. The client enjoys the feeling of being intoxicated. 2. The client uses alcohol to escape from problems. 3. The client has a greater alcohol tolerance than most people. 4. The client performs more efficiently when drinking.

Strategy: Think about each answer. (1) this may be the behavior exhibited while intoxicated, but clients use the effects of alcohol to avoid dealing with problems (2) CORRECT—alcoholics use alcohol to escape from problems as a way to decrease anxiety and tension; frequently, alcoholics will use alcohol to cover depression or anxiety rather than seek out treatment for these problems (3) because of the body's response to the drug, eventually will take more alcohol to attain the same effect, but does not mean they have a higher tolerance than others; after almost any person has ingested a large volume of alcohol habitually for a period of time, s/he develops a tolerance (4) alcohol is a central nervous system depressant; excessive intake causes poor psychomotor coordination, impaired thinking, memory loss, drowsiness, slurred speech, and diminished reflexes

The LPN/LVN cares for a client with cancer receiving chemotherapy. The client shares with the LPN/LVN how upset she is that she is losing her hair. Which of the following statements by the LPN/LVN is BEST? 1. "I'm sure that your daughter will help you find a wig that you like." 2. "I would not want to lose my hair!" 3. "Your hair will grow back about one month after chemotherapy is complete." 4. "There are many attractive hats and scarves that will look very good on you."

Strategy: "BEST" indicates discrimination is required to answer the question. (1) alopecia caused by chemotherapy; this response negates the client's feelings (2) nontherapeutic; focus of response is on LPN/LVN and not the client (3) CORRECT—reassure client that hair loss is temporary; new hair may be a different color, texture, and thickness (4) therapeutic communication reflects client's feelings and/or gives information; this response offers client a solution

A client with a diagnosis of severe anxiety does not eat sufficiently and begins to lose weight. Which of these approaches by the LPN/LVN is BEST for this client? 1. Serve the client's meals on a tray in client's room. 2. Sit with the client during mealtime and encourage eating. 3. Give the client high-calorie foods and drinks to carry. 4. Set limits on the client's activities in the dining room.

Strategy: "BEST" indicates discrimination is required to answer the question. (1) don't isolate the client (2) CORRECT—provide pleasant surroundings and companionship during meals; offer more frequent feeding and favorite foods because of decreased appetite (3) appropriate action for manic client (4) may be required if client is manic and is manipulative

The LPN/LVN cares for a client in the extended care facility diagnosed with a right-sided cerebrovascular accident. The client shouts to the LPN/LVN, "I can't imagine how I am going to live my life with this disability." Which of the following responses by the LPN/LVN is BEST? 1. "You will learn to cope with your disability." 2. "Don't you want to keep going to your grandchildren's sporting events?" 3. "Look how much more you can do now than when I first met you." 4. "It sounds like you are feeling frustrated."

Strategy: "BEST" indicates discrimination is required to answer the question. (1) nontherapeutic; client expressing frustration, does not believe that he will learn how to cope (2) nontherapeutic; nurse should focus on the feelings the client is expressing (3) nontherapeutic; avoid excessive cheeriness and pep talks; client will not believe it (4) CORRECT client expressing feelings of frustration and depression; important that LPN/LVN allows clients to express these feelings

The LPN/LVN cares for clients in the long-term care facility. The wife of a newly admitted client paces the room and says repeatedly, "I didn't want to have to bring my husband here." Which of the following responses by the LPN/LVN is BEST? 1. "You did the best that you could do." 2. "Couldn't your children have helped you more?" 3. "This sounds like it was a difficult decision for you." 4. "We will take good care of him."

Strategy: "BEST" indicates discrimination is required to answer the question. (1) nontherapeutic; negates the wife's feelings (2) nontherapeutic; asking a yes/no question (3) CORRECT reflects the wife's feelings and allows the wife to verbalize (4) nontherapeutic; focus is not on the wife and her feelings

A client is scheduled for a total laryngectomy. He tells the LPN/LVN, "I am worried about my operation. I just can't help it." Which of the following responses by the LPN/LVN is BEST? 1. "Have you discussed your worries with your doctor?" 2. "I hear your concerns about having the operation." 3. "You have a really fine doctor, so there seems to be little need to worry." 4. "Everyone worries about surgery, especially when it is a first-time experience."

Strategy: "BEST" indicates discrimination is required to answer the question. (1) questions that can be answered with a yes/no response are not therapeutic; passing the buck—the LPN/LVN should respond (2) CORRECT—validates the client's concerns and encourages verbalization about the surgery (3) "don't worry" response; false reassurance; doesn't allow client the opportunity to verbalize (4) does reflect the client's concern but is a closed response and doesn't give the client the opportunity to verbalize feelings

The LPN/LVN cares for a client newly diagnosed with paranoid schizophrenia. The client tells the LPN/LVN, "There are really strange people in the corner of my room laughing at me and saying horrible things." Which of the following responses by the LPN/LVN is MOST appropriate? 1. "I don't see anything, and you really have nothing to be ashamed of." 2. "I don't hear the voices, but this seems to be frightening you." 3. "What are they saying to you?" 4. "Sometimes when people are upset, their imagination plays tricks on them."

Strategy: Use therapeutic communication. (1) maintain accepting attitude; don't argue with client; adds extra data for a client whose reality includes fantasy elements (2) CORRECT—the nurse helps the client separate fantasy from reality, and the nurse protects the client's ego by not humiliating him or attempting to talk him out of his hallucination (3) do not reinforce hallucination by validating it; asking client to repeat "horrible" things will serve to cause more discomfort (4) response should validate reality; because client is seeing "really strange people" who are "saying horrible things," comfort and reassurance is needed