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A client is admitted to an inpatient psychiatric unit, and the antipsychotic medication clozapine is prescribed. Which intervention should the nurse include in this client's plan of care?
- A. Inform unlicensed assistive personnel (UAP) that the client will likely complain of a sore throat and fever.
- B. Place the client in protective isolation for the first two weeks of treatment with this medication.
- C. Offer this medication to the client with food to decrease the possibility of gastric upset.
- D. Report findings from the client's weekly white blood cell (WBC) counts to the healthcare provider.
Correct Answer: D
Rationale: Clozapine is associated with the risk of agranulocytosis, so regular monitoring of WBC counts and reporting findings to the healthcare provider is essential.
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A client who is experiencing a severe level of anxiety reports a racing heartbeat, dizziness, and expresses a sense that something dreadful will happen. The nurse observes the client pacing and waving hands rapidly. Which action should the nurse take?
- A. Help the client identify thoughts that may be triggers.
- B. Explore past behaviors that have provided relief.
- C. Attempt to distract to another focus or activity.
- D. Speak calmly to the client stating assurance of safety.
Correct Answer: D
Rationale: Speaking calmly and providing assurance of safety is the first step in managing severe anxiety, helping to stabilize the client.
A female client with obsessive-compulsive personality disorder is admitted to the hospital for a cardiac catheterization. The afternoon before the procedure, the client begins to keep detailed notes of the nursing care she is receiving, and reports her findings to the nurse at bedtime. What action should the nurse implement?
- A. Explain to the client that her behavior invades the rights of the nursing staff.
- B. Teach the client strategies to control her obsessive-compulsive behavior.
- C. Ask the client to explain why she is keeping a detailed record of her nursing care.
- D. Encourage the client to express her feelings regarding the upcoming procedure.
Correct Answer: D
Rationale: Encouraging the client to express feelings regarding the upcoming procedure addresses potential anxiety driving the behavior, offering a therapeutic approach.
A client with opioid dependence makes a statement to the nurse about desiring to lead a healthier lifestyle by making changes in the next 2 weeks. How should the nurse respond?
- A. Support the client to list small behavioral changes needed.
- B. Explain the specific skills needed to prevent a relapse.
- C. Provide teaching on the symptoms of substance use dependence.
- D. Advise the client to reschedule until committing to recovery.
Correct Answer: A
Rationale: Supporting the client to list small behavioral changes is a person-centered approach that promotes achievable progress toward a healthier lifestyle.
Which interventions should the nurse include in the plan of care for an adolescent who is depressed? (Select all that apply.)
- A. Reinforce statements regarding a will to live and realistic plans for the future.
- B. Discuss the client's suicide plan.
- C. Limit time allowed to play video games.
- D. Encourage the client to discuss thoughts and feelings about wanting to die.
- E. Restrict visitors to family members only.
Correct Answer: A,B,D
Rationale: Reinforcing a will to live, discussing suicide plans, and encouraging expression of suicidal thoughts promote hope, assess risk, and ensure safety.
Which individual should the nurse consider at the highest risk for suicide?
- A. A nurse who works in a pediatric emergency department.
- B. An adolescent male whose parents recently divorced.
- C. A retired older male whose significant other has passed away.
- D. A single working mother with three preschool-aged children.
Correct Answer: B
Rationale: Adolescents experiencing major life changes, such as parental divorce, are at an elevated risk for suicide due to emotional and social stressors.