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During an exacerbation of schizophrenia symptoms, which intervention should the nurse prioritize for a client with a history of schizophrenia?
- A. Encourage adherence to the medication regimen.
- B. Increase social interactions with peers.
- C. Provide a high-stimulation environment.
- D. Assess for safety risks related to the exacerbation.
Correct Answer: D
Rationale: During an exacerbation of schizophrenia symptoms, the nurse should prioritize assessing for safety risks. This is critical because individuals with schizophrenia may experience heightened risks to themselves or others during this period. Encouraging adherence to the medication regimen (Choice A) is important but ensuring immediate safety takes precedence. Increasing social interactions with peers (Choice B) and providing a high-stimulation environment (Choice C) can potentially exacerbate symptoms and should be avoided during an exacerbation.
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While interviewing a client, the nurse takes notes to assist with accurate documentation later. Which statement is most accurate regarding note-taking during an interview?
- A. The client's comfort level is increased when the nurse maintains eye contact while taking notes.
- B. The interview process is enhanced with note-taking, allowing the client to speak at a normal pace.
- C. Note-taking during an interview is not a legal obligation of the examining nurse.
- D. The nurse's ability to directly observe the client's nonverbal communication is limited with note-taking.
Correct Answer: D
Rationale: During an interview, note-taking can hinder the nurse's ability to directly observe the client's nonverbal cues such as body language, facial expressions, and tone of voice. These nonverbal cues are crucial for understanding the client's emotions, feelings, and overall communication. Therefore, it is essential for the nurse to strike a balance between note-taking for documentation purposes and actively observing the client's nonverbal communication to ensure a comprehensive assessment. Choices A, B, and C are incorrect because maintaining eye contact, enhancing the interview process with note-taking, and legal obligations of note-taking during an interview do not directly address the issue of limited observation of nonverbal communication while taking notes.
Gilbert, age 19, is described by his parents as a 'moody child' with an onset of odd behavior around age 14, which caused him to suffer academically and socially. Gilbert has lost the ability to complete household chores, is reluctant to leave the house, and is obsessed with the locks on the windows and doors. Due to Gilbert's early and slow onset of what is now recognized as schizophrenia, his prognosis is considered:
- A. Favorable with medication
- B. In the relapse stage
- C. Improvable with psychosocial interventions
- D. To have a less positive outcome
Correct Answer: D
Rationale: In cases of early and slow onset of schizophrenia, the prognosis is generally less positive. This means that the outlook for individuals like Gilbert, who showed signs of schizophrenia at a young age, is often poorer. Option A is incorrect because while medication can help manage symptoms, the overall prognosis is still less favorable. Option B is incorrect since relapse stage typically refers to a period of worsening symptoms after initial improvement. Option C is incorrect because while psychosocial interventions can be beneficial, the underlying early and slow onset of schizophrenia indicates a less positive outcome.
The nurse on the evening shift receives report that a client is scheduled for electroconvulsive treatment (ECT) in the morning. Which intervention should the nurse implement the evening before the scheduled ECT?
- A. Hold all bedtime medication.
- B. Keep the client NPO after midnight.
- C. Implement elopement precautions.
- D. Give the client an enema at bedtime.
Correct Answer: B
Rationale: Keeping the client NPO after midnight is essential to prevent aspiration during the ECT procedure. Choice A, holding all bedtime medication, is not necessary unless specified by the healthcare provider. Choice C, implementing elopement precautions, is unrelated to preparing for ECT. Choice D, giving the client an enema at bedtime, is not a standard pre-ECT intervention.
An elderly client diagnosed with delirium is being treated with antipsychotic medication. Which side effect should the nurse monitor for in this client?
- A. Akathisia
- B. Hallucinations
- C. Orthostatic hypotension
- D. Drowsiness
Correct Answer: C
Rationale: The correct side effect that the nurse should monitor for in an elderly client diagnosed with delirium and treated with antipsychotic medication is orthostatic hypotension. Antipsychotic medications can lead to a drop in blood pressure upon standing, particularly in elderly individuals. Akathisia (choice A) refers to a movement disorder characterized by a feeling of inner restlessness and a compelling need to be in constant motion, which can be a side effect of antipsychotic medications but is not specific to elderly clients with delirium. Hallucinations (choice B) are sensory perceptions that appear real but are created by the mind, and while they can be associated with certain conditions or medications, they are not a common side effect of antipsychotic medications in elderly clients with delirium. Drowsiness (choice D) is a general CNS depressant effect that can occur with antipsychotic medications but is not the specific side effect that the nurse should be monitoring for in this case.
An adolescent with anorexia nervosa is undergoing nutritional therapy. Which finding best indicates that the client is making progress in treatment?
- A. Client gains 2 pounds in a week.
- B. Client describes a positive body image.
- C. Client engages in recreational activities.
- D. Client begins to talk about future goals.
Correct Answer: A
Rationale: The correct answer is A. Weight gain is a crucial indicator of progress in the treatment of anorexia nervosa. In individuals with anorexia, restoring and maintaining a healthy weight is a primary goal to address the underlying nutritional deficiencies and health complications associated with the disorder. While choices B, C, and D are positive developments in the client's overall well-being and recovery journey, they are not as directly linked to the core issue of nutritional rehabilitation in anorexia nervosa. Describing a positive body image, engaging in recreational activities, and talking about future goals are important aspects of psychological and emotional recovery, but weight gain is a more immediate and objective measure of progress in treating anorexia nervosa.