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A client diagnosed with schizophrenia has been receiving haloperidol for the past year, and the treatment plan includes moving the client to a lower maintenance dosage. Which intervention should the nurse include in this client's plan of care? (Select all that apply)
- A. Shielding the client from direct sunlight when outdoors.
- B. Gradually withdrawing the medication over several days.
- C. Enforcing a fluid restriction during dosage adjustment.
- D. Increasing the dosage if the white blood cell count drops.
Correct Answer: A,B
Rationale: Shielding from sunlight prevents sunburn due to haloperidol's photosensitivity, and gradual withdrawal avoids symptom worsening.
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An adolescent who is a heroin addict is admitted to the unit for detoxification. What intervention is most important for the nurse to initiate during the first 24 hours after admission?
- A. Assess intake and output.
- B. Monitor for wheezing and apnea.
- C. Limit visitors to family members only.
- D. Assign the client to a teen support group.
Correct Answer: B
Rationale: Monitoring for wheezing and apnea is crucial during the first 24 hours of heroin detoxification to ensure respiratory stability, addressing immediate physiological risks.
After meeting with a healthcare provider, a client who is diagnosed with bipolar disorder is screaming and stomping both feet while pacing the hallway. Which action should the nurse take?
- A. Instruct the client to reduce the volume of his voice.
- B. Accompany the client to a quiet area of the unit.
- C. Encourage the client to attend a support group.
- D. Administer a PRN sedative by injection.
Correct Answer: B
Rationale: Accompanying the client to a quiet area provides a calming environment, helping to deescalate the client's agitated state.
The nurse develops a plan of care for a female client who scratches her wrists in attempts to deal with anxiety. Which client outcome is most important to include in the plan of care?
- A. Participates in individual and group therapy.
- B. Demonstrates effective ways to cope with anxiety.
- C. Takes all antianxiety medications as prescribed.
- D. Learns methods of relaxation to reduce anxiety.
Correct Answer: B
Rationale: Demonstrating effective ways to cope with anxiety is the most important outcome to address the client's self-harming behavior and promote healthier coping mechanisms.
The charge nurse of the psychiatric unit observes clients in the day area. Which client is exhibiting symptoms of a conversion disorder?
- A. A young woman who suddenly goes blind with no indication of organic pathology.
- B. An older adult who continuously complains of a headache and back pain.
- C. An adolescent who becomes extremely anxious about going outside.
- D. A middle-aged man who is complaining of shortness of breath and is diaphoretic.
Correct Answer: A
Rationale: Sudden blindness with no organic pathology is indicative of a conversion disorder, involving neurological symptoms without a neurological basis.
While assessing a client with the diagnosis of schizophrenia who wears dentures, the nurse observes that the client's tongue is “wormingâ€. The client also demonstrates an inability to articulate words clearly. Which additional assessment is most important for the nurse to obtain?
- A. Usual level of activity and average sleep pattern.
- B. Blood pressure when sitting and standing.
- C. Dentures to determine if they are poorly fitted.
- D. Body weight over the past three months.
Correct Answer: C
Rationale: Assessing the fit of dentures is crucial, as poorly fitted dentures could contribute to speech difficulties and tongue abnormalities observed.