Nokea
A 19-year-old client is admitted for the second time in 9 months and is acutely psychotic with a diagnosis of undifferentiated schizophrenia. The client sits alone rubbing her arms and smiling. She tells the nurse her thoughts cause earthquakes and that the world is burning. The nurse assesses the primary deficit associated with the client's condition as:
- A. Altered mood states
- B. Disturbed thinking
- C. Social isolation
- D. Poor impulse control
Correct Answer: B
Rationale: The correct answer is B: Disturbed thinking. This is because the client's belief that her thoughts cause earthquakes and the world is burning indicates a break from reality, a hallmark of psychosis in schizophrenia. This demonstrates disorganized and illogical thinking, a key symptom of disturbed thinking. The other choices are incorrect because: A) Altered mood states typically refer to emotional disturbances, which are not the primary deficit in this scenario; C) Social isolation is a consequence of the client's symptoms but not the primary deficit; D) Poor impulse control is not the primary deficit in this case as the client's behavior is more indicative of disorganized thinking.
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Marty is a 15-year-old boy whose parents have brought him to a mental health clinic for evaluation. They are concerned because his grades have fallen and he has become angry and sometimes even violent. He spends long periods of time alone and does not want to see his friends. The parents report that he has never been a bad boy nor had problems in school. They are worried about the changes in his behavior. Which of the following is the most likely cause?
- A. Depression
- B. Running around with a tough crowd
- C. Normal adolescent phase
- D. Attention deficit hyperactivity disorder
Correct Answer: A
Rationale: In addition to classic symptoms of depression, adolescents often display irritability and problems in school performance. This is not normal teen behavior. Because Marty has been functioning well in school up until now, it is unlikely that ADHD would be exhibited at this point.
When teaching a patient with binge-purge bulimia, the nurse should give priority to information about:
- A. Self-monitoring of daily food and fluid intake.
- B. Establishing the desired daily weight gain.
- C. Symptoms of hypokalemia.
- D. Self-esteem maintenance
Correct Answer: C
Rationale: The correct answer is C: Symptoms of hypokalemia. This is the priority because individuals with binge-purge bulimia often have electrolyte imbalances, including hypokalemia, which can lead to serious cardiac complications. Educating the patient on recognizing symptoms of hypokalemia, such as weakness, fatigue, and irregular heartbeats, is crucial for early intervention.
A: Self-monitoring of daily food and fluid intake is important but not the priority when dealing with potential life-threatening complications like hypokalemia.
B: Establishing the desired daily weight gain is not appropriate for individuals with binge-purge bulimia as the focus should be on addressing the underlying psychological issues rather than weight gain.
D: Self-esteem maintenance is important in the long term but does not take precedence over addressing immediate health risks such as hypokalemia.
A patient diagnosed with a serious mental illness lives independently and attends a psychosocial rehabilitation program. The patient presents at the emergency department seeking hospitalization. The patient has no acute symptoms but says, 'I have no money to pay my rent or refill my prescription.' Select the nurses best action.
- A. Involve the patients case manager to provide crisis intervention
- B. Send the patient to a homeless shelter until housing can be arranged
- C. Arrange for a short in-patient admission and begin discharge planning
- D. Explain that one must have active psychiatric symptoms to be admitted
Correct Answer: A
Rationale: Impaired stress tolerance and problem-solving abilities can cause persons with SMI to experience relatively minor stressors as crises. This patient has run out of money, and this has overwhelmed her ability to cope, resulting in a crisis for which crisis intervention would be an appropriate response. Inpatient care is not clinically indicated nor is the patient homeless (although she may fear she is). Telling the patient that she is not symptomatic enough to be admitted may prompt malingering.
The intervention of highest priority for a client with stage 3 Alzheimer's disease is to:
- A. Provide a stimulating environment
- B. Maintain hydration and nutrition
- C. Set limits on behavioral disinhibition
- D. Promote self-care activities
Correct Answer: B
Rationale: The correct answer is B because maintaining hydration and nutrition is crucial for the client's overall well-being and health in stage 3 Alzheimer's. Dehydration and malnutrition can lead to serious complications. Providing a stimulating environment (choice A) may be beneficial but not the highest priority. Setting limits on behavioral disinhibition (choice C) may be challenging due to the progression of the disease. Promoting self-care activities (choice D) may not be feasible as the client's cognitive abilities decline. Maintaining hydration and nutrition is essential for the client's survival and quality of life.
A client on an antipsychotic medication develops a high fever, unstable blood pressure, and muscle rigidity. Her next dose of medication is due. The nurse should:
- A. Administer the medication and take the vital signs again
- B. Give a lower dose of the medication and take the blood pressure
- C. Prepare to give the pm anticholinergic, benztropine (Cogentin)
- D. Hold the medication and call the client's doctor immediately
Correct Answer: D
Rationale: The correct answer is D: Hold the medication and call the client's doctor immediately. This is the correct course of action because the client is exhibiting signs of neuroleptic malignant syndrome (NMS), a potentially life-threatening side effect of antipsychotic medications. Holding the medication is essential to prevent further complications. Calling the doctor is necessary to inform them of the situation and seek further instructions. Administering the medication (choice A) would exacerbate the symptoms, giving a lower dose (choice B) is not sufficient in this emergency situation, and administering an anticholinergic (choice C) is not the appropriate response for NMS.