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A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of risperidone (Risperdal). When the client walks to the nurse’s station in a laterally contracted position, he states that something has made his body contort into a monster. What action should the nurse take?
- A. Medicate the client with the prescribed antipsychotic thioridazine (Mellaril)
- B. Offer the client a prescribed physical therapy hot pack for muscle spasms.
- C. Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia.
- D. Direct client to occupational therapy to distract him from somatic complaints.
Correct Answer: C
Rationale: The correct action is to administer the prescribed anticholinergic benztropine (Cogentin) for dystonia. Dystonia is a side effect of antipsychotic medications like risperidone and can present as abnormal muscle contractions or postures. Benztropine is commonly used to manage dystonia by blocking excess acetylcholine in the brain. This helps to alleviate the muscle spasms and contractions that the client is experiencing. Mediating with thioridazine may not be appropriate as it is not the prescribed medication and may not effectively address the dystonia. Offering a hot pack for muscle spasms might provide temporary relief but does not address the underlying cause of dystonia. Directing the client to occupational therapy or distracting him may not effectively manage the dystonia symptoms. Administering benztropine is the most appropriate action to address the client's physical symptoms and improve his comfort and well-being.
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Which statement demonstrates a well-structured attempt at limit setting?
- A. Hitting me when you are angry is unacceptable.
- B. I expect you to behave yourself during dinner.
- C. Come here, right now!
- D. Good boys don’t bite.
Correct Answer: A
Rationale: The correct answer is A because it clearly communicates the behavior that is unacceptable (hitting when angry) and sets a clear boundary. It addresses the specific behavior and its consequences without being vague or ambiguous. Choice B lacks specificity, choice C is a command without explaining the reason for the request, and choice D uses shaming language which is not effective in setting limits. Choices E, F, and G are irrelevant as they are not provided. Overall, choice A demonstrates a well-structured attempt at limit setting by being clear, specific, and focusing on the behavior that needs to change.
A middle-aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and amotivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning?
- A. Encourage the client to exercise.
- B. Suggest that the client develop a list of pleasurable activities.
- C. Provide education on methods to enhance sleep.
- D. Teach the client to develop a plan for daily structured activities.
Correct Answer: D
Rationale: The correct answer is D: Teach the client to develop a plan for daily structured activities. This intervention is most effective because it addresses the symptoms presented by the client - psychomotor retardation, hypersomnia, and amotivation. Structured activities can help regulate the client's daily routine, combat inertia, and provide a sense of purpose and accomplishment. By setting specific tasks and goals, the client can gradually increase their level of activity and engagement, which can improve mood and motivation. Encouraging exercise (choice A) may be beneficial, but developing a structured plan encompasses a broader approach to address all symptoms. Creating a list of pleasurable activities (choice B) may not address the lack of motivation or structure. Providing education on sleep enhancement methods (choice C) may not directly address psychomotor retardation and amotivation.
The RN is providing care for a client diagnosed with borderline personality disorder who has self-inflicted lacerations on the abdomen. Which approach should the RN use when changing this client’s dressing?
- A. Provide detailed thorough explanations when cleansing wound.
- B. Perform the dressing change in a non-judgmental manner.
- C. Ask in a non-threatening manner why the client cut own abdomen.
- D. Request another staff member assist with the dressing change.
Correct Answer: B
Rationale: The correct answer is B: Perform the dressing change in a non-judgmental manner. When caring for a client with borderline personality disorder who has self-inflicted injuries, it is crucial to approach the situation with empathy and without passing judgment. This approach helps build trust, maintains the therapeutic relationship, and encourages open communication. Providing detailed explanations (choice A) may overwhelm the client. Asking about the self-inflicted behavior (choice C) in a non-threatening manner can be appropriate but should not be the primary focus during the dressing change. Requesting another staff member's assistance (choice D) may not be necessary if the RN can handle the situation effectively.
A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The RN also determines that the client is homeless and is exhibiting suspiciousness. The client’s plan of care should include what priority problem?
- A. Acute confusion.
- B. Ineffective community coping
- C. Disturbed sensory perception.
- D. Self-care deficit.
Correct Answer: A
Rationale: The correct answer is A: Acute confusion. This is the priority problem because the client is disoriented, disorganized, and confused, indicating an altered mental status requiring immediate attention. Addressing acute confusion is crucial to ensure the client's safety and well-being.
Incorrect Choices:
B: Ineffective community coping is not the priority as the client's immediate cognitive impairment takes precedence.
C: Disturbed sensory perception does not align with the client's presentation of confusion and disorientation.
D: Self-care deficit may be a concern but is secondary to the acute confusion that needs urgent intervention.
A young adult female visits the mental health clinic complaining of diarrhea, headache, and muscle aches. She is afebrile, denies chills, and all laboratory findings are within normal limits. During the physical assessment, the client tells the RN that her sister thinks she is neurotic and calls her a hypochondriac. Which response is best for the RN to provide?
- A. Unless your sister has a medical education, ignore her comments.
- B. I can hear that your sister comments are over-whelming you.
- C. Do you think it’s possible that you might be a hypochondriac?
- D. Besides your sister’s comments, what in your life is troubling you?
Correct Answer: B
Rationale: The correct answer is B: "I can hear that your sister's comments are overwhelming you." This response acknowledges the client's feelings and shows empathy, validating her experience. It demonstrates active listening and understanding without judgment. Choice A dismisses the client's feelings, which can be harmful. Choice C may come off as accusatory and may make the client defensive. Choice D shifts the focus away from the client's emotions, missing an opportunity for therapeutic communication.