Nokea
A client has been prescribed lorazepam (Ativan) for the treatment of anxiety. Which of the following instructions should the nurse include?
- A. Take the medication with food to avoid stomach upset.
- B. Avoid driving until you know how the medication affects you.
- C. Take the medication on an empty stomach.
- D. Double the dose if you miss a dose.
Correct Answer: B
Rationale: The correct answer is B because lorazepam (Ativan) can cause dizziness and drowsiness, so the client should avoid driving until they know how the medication affects them. This instruction is crucial for ensuring the client's safety and preventing any potential accidents or harm. Choice A is incorrect because lorazepam does not necessarily need to be taken with food. Choice C is incorrect as it contradicts the usual recommendation of taking lorazepam with or without food. Choice D is incorrect and dangerous advice as doubling the dose of lorazepam can lead to overdose and serious complications.
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A client is being assessed by a nurse after being diagnosed with anorexia nervosa. Which of the following findings should the nurse expect?
- A. Weight gain and increased appetite
- B. Lanugo on the face and back
- C. Increased body temperature and tachycardia
- D. Hyperactivity and distractibility
Correct Answer: B
Rationale: In anorexia nervosa, individuals often develop lanugo, fine soft hair, on the face and back. This is a physiological response to the body's attempt to conserve heat due to a lack of subcutaneous fat. It is a common physical finding in clients with anorexia nervosa and can be a sign of severe malnutrition. Choices A, C, and D are incorrect because weight gain and increased appetite, increased body temperature and tachycardia, and hyperactivity and distractibility are not typically associated with anorexia nervosa. In fact, weight loss, decreased appetite, hypothermia, and bradycardia are more commonly seen in individuals with anorexia nervosa.
When assessing a client diagnosed with post-traumatic stress disorder (PTSD), which finding should the nurse expect?
- A. Hypervigilance
- B. Insomnia
- C. Flashbacks
- D. Suicidal ideation
Correct Answer: A
Rationale: Clients with PTSD commonly exhibit symptoms such as hypervigilance, insomnia, flashbacks, difficulty concentrating, and increased irritability. Hypervigilance refers to an enhanced state of awareness and alertness, often seen in individuals with PTSD as they are constantly on guard for potential threats. Insomnia is a common sleep disturbance associated with PTSD, where individuals may have trouble falling or staying asleep. Flashbacks involve re-experiencing the traumatic event as if it is occurring in the present moment. Suicidal ideation, while a serious concern in mental health, is not a hallmark symptom specifically associated with PTSD. Therefore, the correct finding that the nurse should expect when assessing a client diagnosed with PTSD is hypervigilance.
A client has been diagnosed with post-traumatic stress disorder (PTSD) and is having nightmares about the event. The client reports difficulty sleeping at night. Which of the following actions should the nurse take first?
- A. Encourage the client to talk about the event during the day.
- B. Encourage the client to avoid caffeine and alcohol.
- C. Administer a prescribed sedative at bedtime.
- D. Schedule a follow-up appointment with the client's therapist.
Correct Answer: A
Rationale: The initial action the nurse should take is to encourage the client to talk about the traumatic event during the day. This approach can assist the client in processing the trauma in a controlled environment, potentially reducing the frequency and intensity of nightmares. It allows for emotional expression and may promote better sleep by addressing the underlying psychological distress associated with PTSD. Encouraging the client to talk about the event during the day promotes therapeutic processing of the trauma and emotional expression, which can lead to improved coping mechanisms and potentially decrease the distressing symptoms like nightmares. Encouraging the client to avoid caffeine and alcohol may be beneficial, but addressing the emotional aspects first is crucial. Administering a sedative should not be the first approach, as it does not address the root cause of the nightmares. Scheduling a follow-up appointment with the therapist is important but should follow addressing the immediate distressing symptoms and promoting coping strategies.
Upon admission, a client diagnosed with major depressive disorder needs the nurse to implement which of the following interventions first?
- A. Administer an antidepressant medication.
- B. Establish a trusting relationship with the client.
- C. Develop a plan of care with the client.
- D. Teach the client about the importance of medication compliance.
Correct Answer: B
Rationale: The initial intervention the nurse should prioritize is to establish a trusting relationship with the client. Building trust is fundamental in fostering effective therapeutic communication and providing quality care. This foundational step lays the groundwork for further assessment, collaboration on care plans, and promoting treatment adherence. Administering medication or discussing compliance should come after the establishment of trust to ensure the client feels supported and understood.
A healthcare professional is assessing a client diagnosed with paranoid schizophrenia. Which of the following findings should the healthcare professional expect?
- A. Auditory hallucinations
- B. Delusions of grandeur
- C. A flat affect
- D. Disorganized speech
Correct Answer: B
Rationale: The correct answer is B: Delusions of grandeur. Clients with paranoid schizophrenia often experience delusions of grandeur or persecution, auditory hallucinations, and a flat affect. However, the most characteristic finding for paranoid schizophrenia is the presence of delusions, which are fixed false beliefs that are not based in reality. Delusions of grandeur, where individuals believe they are exceptionally powerful or important, are commonly seen in paranoid schizophrenia. Choice A, auditory hallucinations, are more commonly associated with other types of schizophrenia such as paranoid or disorganized schizophrenia. Choice C, a flat affect, is a symptom that can be seen across various types of schizophrenia. Choice D, disorganized speech, is more indicative of disorganized schizophrenia.