LVN Psychosocial Integrity Test 2 — Questions and Answers
Question 1: A patient diagnosed with schizophrenia is experiencing auditory hallucinations. Which nursing intervention is most appropriate?
- Administering a sedative medication
- Encouraging the patient to discuss the hallucinations (Correct answer)
- Ignoring the hallucinations to avoid reinforcing them
- Restraining the patient to prevent self-harm
Correct answer: Encouraging the patient to discuss the hallucinations
Encouraging a patient with schizophrenia to discuss their auditory hallucinations in a non-judgmental way is the most appropriate intervention. This approach validates the patient's experience, helps the nurse understand the nature and impact of the hallucinations, and builds trust. It allows for assessment and appropriate intervention without ignoring or reinforcing the delusion.
Question 2: A patient with depression has been prescribed fluoxetine (Prozac). The nurse should monitor the patient for which potential adverse effect?
- Hypotension
- Weight gain
- Insomnia
- Suicidal ideation (Correct answer)
Correct answer: Suicidal ideation
Fluoxetine (Prozac), an SSRI antidepressant, carries a black box warning for an increased risk of suicidal thoughts and behaviors, especially in children, adolescents, and young adults, particularly at the beginning of treatment or with dose changes. While the medication can improve mood, it may initially increase energy before mood fully lifts, potentially giving patients the impetus to act on suicidal ideation. Therefore, close monitoring is crucial.
Question 3: Which nursing action is most important when caring for a patient with bipolar disorder during a manic episode?
- Ensuring a quiet, low-stimulation environment (Correct answer)
- Providing frequent opportunities for social interaction
- Limiting physical activity to conserve energy
- Allowing the patient to make financial decisions independently
Correct answer: Ensuring a quiet, low-stimulation environment
During a manic episode, a patient with bipolar disorder experiences elevated energy, racing thoughts, and is easily overstimulated. Ensuring a quiet, low-stimulation environment helps to reduce agitation, promote rest, and prevent the escalation of manic symptoms. This intervention is crucial for the patient's safety and to help them regain control.
Question 4: A patient with borderline personality disorder (BPD) exhibits splitting behavior. The nurse understands this behavior involves:
- Switching between extremes of idealization and devaluation (Correct answer)
- Confusion and disorientation
- Impulsivity and risk-taking behaviors
- Severe mood swings and agitation
Correct answer: Switching between extremes of idealization and devaluation
Splitting is a defense mechanism commonly seen in borderline personality disorder (BPD). It involves the inability to integrate positive and negative qualities of oneself or others into a cohesive whole. As a result, individuals with BPD perceive people or situations in extreme, all-good or all-bad terms, rapidly shifting between idealization and devaluation.
Question 5: When communicating with a patient diagnosed with antisocial personality disorder, the nurse should:
- Provide excessive praise and attention for positive behaviors
- Allow the patient to manipulate others to maintain peace
- Avoid confrontation or conflict to prevent aggression
- Set firm boundaries and consequences for inappropriate behavior (Correct answer)
Correct answer: Set firm boundaries and consequences for inappropriate behavior
Patients with antisocial personality disorder often exhibit manipulative and deceitful behaviors, disregarding rules and the rights of others. Setting firm, consistent boundaries and clearly defined consequences is essential to establish limits, promote accountability, and prevent manipulation. This approach fosters a safe and structured therapeutic environment for both the patient and others.
Question 6: Which statement by a patient with generalized anxiety disorder (GAD) indicates a need for further education?
- "I try to avoid caffeine and nicotine to reduce my anxiety."
- "I take my lorazepam (Ativan) as needed when I feel very anxious."
- "I find it helpful to exercise regularly to manage my stress."
- "I drink a glass of wine every night to help me relax before bed." (Correct answer)
Correct answer: "I drink a glass of wine every night to help me relax before bed."
Drinking alcohol to relax before bed indicates a need for further education for a patient with generalized anxiety disorder (GAD). While alcohol may provide temporary relief, it is a central nervous system depressant that can worsen anxiety in the long run, disrupt sleep patterns, and lead to dependence. This coping mechanism is maladaptive and counterproductive for managing anxiety effectively.
Question 7: Which behavior by a patient diagnosed with anorexia nervosa should the nurse prioritize as needing immediate intervention?
- Refusing to participate in group therapy sessions
- Experiencing bradycardia and hypotension (Correct answer)
- Complaining of feeling cold despite warm room temperature
- Expressing a desire to exercise excessively
Correct answer: Experiencing bradycardia and hypotension
Experiencing bradycardia (slow heart rate) and hypotension (low blood pressure) in a patient with anorexia nervosa indicates severe cardiovascular compromise due to malnutrition and electrolyte imbalances. These are critical physiological signs that put the patient at high risk for cardiac arrest and require immediate medical intervention to stabilize their condition. This is a life-threatening emergency.
Question 8: A patient with schizophrenia is prescribed risperidone (Risperdal). The nurse should monitor the patient for which potential adverse effect?
- Weight loss
- Hyperactivity
- Orthostatic hypotension (Correct answer)
- Excessive salivation
Correct answer: Orthostatic hypotension
Risperidone (Risperdal) is an atypical antipsychotic that can cause orthostatic hypotension, a sudden drop in blood pressure upon standing. This adverse effect is due to its alpha-adrenergic blocking properties and can lead to dizziness, lightheadedness, and an increased risk of falls. Therefore, monitoring blood pressure and advising patients to change positions slowly are important nursing actions.
Question 9: A patient with post-traumatic stress disorder (PTSD) is experiencing a flashback. The nurse's priority intervention is to:
- Provide distraction by engaging the patient in a conversation
- Administer a prescribed sedative to calm the patient
- Ensure a safe environment and reassure the patient (Correct answer)
- Encourage the patient to confront and re-experience the traumatic event
Correct answer: Ensure a safe environment and reassure the patient
During a flashback, a patient with PTSD is intensely re-experiencing the traumatic event as if it's happening in the present, leading to extreme fear and disorientation. The nurse's immediate priority is to ensure the patient's physical safety and provide a calm, reassuring presence. This helps to reorient them to reality and create a sense of security, reducing distress.
Question 10: A patient with alcohol use disorder is admitted for detoxification. The nurse understands that the priority during detoxification is to:
- Monitor for signs of delirium tremens (DTs) and manage symptoms (Correct answer)
- Administer benzodiazepines as needed for withdrawal symptoms
- Provide group therapy sessions to explore underlying issues
- Encourage the patient to attend Alcoholics Anonymous (AA) meetings daily
Correct answer: Monitor for signs of delirium tremens (DTs) and manage symptoms
During alcohol detoxification, the absolute priority is to monitor for and manage signs of delirium tremens (DTs). DTs are the most severe and life-threatening manifestation of alcohol withdrawal, characterized by severe agitation, hallucinations, seizures, and autonomic instability. Prompt recognition and intervention are crucial to prevent serious complications and ensure patient safety.
Question 11: When assessing a patient with dementia, the nurse observes repetitive pacing and agitation. The most appropriate nursing intervention is to:
- Administer a sedative medication to promote relaxation
- Redirect the patient's attention to a calming activity (Correct answer)
- Encourage the patient to continue pacing to expend energy
- Restrain the patient to prevent falls and injury
Correct answer: Redirect the patient's attention to a calming activity
Repetitive pacing and agitation in a patient with dementia often stem from confusion, unmet needs, or overstimulation. The most appropriate nursing intervention is to redirect the patient's attention to a calming activity. This helps to de-escalate the agitation, provide a sense of purpose, and reduce distress without resorting to more restrictive measures like sedatives or restraints.
LVN Psychosocial Integrity Test 2
A patient diagnosed with schizophrenia is experiencing auditory hallucinations.
Which nursing intervention is most appropriate?