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A nurse is caring for several clients who have mental health disorders at an assisted-living facility. Which of the following clients should the nurse determine needs to be seen by a provider immediately?
- A. A client who is taking olanzapine and experiences dizziness when first standing up
- B. A client who is taking chlorpromazine and reports vomiting twice
- C. A client who is taking thioridazine and has daytime drowsiness
- D. A client who is taking clozapine and has flu-like manifestations
Correct Answer: D
Rationale: The correct answer is D. Clozapine is associated with a serious side effect called agranulocytosis, which can manifest as flu-like symptoms such as fever, sore throat, and malaise. Agranulocytosis is a potentially life-threatening condition that requires immediate medical attention to prevent complications. Clients taking clozapine should be monitored closely for signs of infection. Choices A, B, and C describe common side effects of antipsychotic medications that are not typically considered emergencies. For example, dizziness upon standing (A), vomiting (B), and daytime drowsiness (C) are known side effects that may not require immediate medical attention unless severe or persistent. Therefore, the client taking clozapine with flu-like manifestations (D) should be seen by a provider immediately due to the potential seriousness of agranulocytosis.
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A nurse in a mental health clinic is assessing a client who was brought in by her adult daughter stating that her mother has not been able to leave her home for weeks because she is afraid to be outdoors alone. The nurse should anticipate planning care for managing which of the following phobias?
- A. Xenophobia
- B. Acrophobia
- C. Mysophobia
- D. Agoraphobia
Correct Answer: D
Rationale: Agoraphobia is the fear of being in open or public spaces, leading to avoidance behavior.
A nurse is caring for a client who has schizophrenia and is experiencing a hallucination. Which of the following actions should the nurse take?
- A. Act as if the hallucination is real.
- B. Instruct the client to argue with the voices that are a part of the hallucination.
- C. Ask the client direct questions about the hallucination.
- D. Tell the client that the hallucination is not a part of reality.
Correct Answer: C
Rationale: The correct answer is C - Ask the client direct questions about the hallucination. This approach helps the nurse understand the client's experience without validating or denying the hallucination. It shows empathy and promotes trust. Choice A would validate the hallucination, worsening the client's condition. Choice B could escalate the situation by encouraging confrontation with the voices. Choice D may cause the client to feel dismissed or judged. Asking direct questions (C) allows the nurse to gather information, assess the client's safety, and provide appropriate care.
A nurse is assessing a client who is to undergo a left lobectomy to treat lung cancer. The client tells the nurse that she is scared and wishes she had never smoked. Which of the following responses should the nurse make?
- A. "It's okay to feel scared. Let's talk about what you are afraid of."
- B. "Don't worry. The important thing is you have now quit smoking."
- C. "I understand your fears. I was a smoker also."
- D. "Your doctor is a great surgeon. You will be fine."
Correct Answer: A
Rationale: The correct answer is A: "It's okay to feel scared. Let's talk about what you are afraid of." This response shows empathy and acknowledges the client's feelings, which is an essential aspect of therapeutic communication. By inviting the client to talk about her fears, the nurse creates a safe space for the client to express her emotions and concerns. This can help alleviate anxiety and build trust between the client and the nurse.
Choices B, C, and D are incorrect because they do not directly address the client's emotional state or offer support. B focuses on smoking cessation, which may not be the immediate concern for the client undergoing surgery. C shifts the focus to the nurse's personal experience, which may detract from the client's needs. D dismisses the client's fears and offers reassurance without addressing the underlying emotions.
A charge nurse is discussing suicide interventions with nursing staff. Which of the following should the nurse identify as an example of secondary intervention?
- A. Providing support for family and friends following a suicide.
- B. Identifying individuals who are at higher risk for attempting suicide.
- C. Recognizing the warning signs of suicide.
- D. Performing life-saving measures following a suicide attempt.
Correct Answer: D
Rationale: Secondary intervention involves direct care during a suicide crisis, such as life-saving measures.
A nurse is caring for a client who has schizophrenia. Which of the following statements by the client indicates understanding of a relapse prevention plan?
- A. "I can remember when my hallucinations first began."
- B. "I know which of my hallucinations trigger a relapse."
- C. "I record the number of hallucinations I have each day."
- D. "I will read as much information as I can about schizophrenia."
Correct Answer: B
Rationale: Correct Answer: B
Rationale: Option B, "I know which of my hallucinations trigger a relapse," indicates the client's understanding of identifying triggers for relapse. This awareness is crucial in preventing relapse by avoiding or managing triggers effectively. Understanding personal triggers helps the client take proactive steps to maintain stability.
Incorrect Choices:
A: "I can remember when my hallucinations first began." This statement does not demonstrate a proactive plan for relapse prevention.
C: "I record the number of hallucinations I have each day." Monitoring hallucinations is important but does not necessarily indicate understanding of relapse prevention.
D: "I will read as much information as I can about schizophrenia." While education is vital, it does not directly address relapse prevention strategies.