Nokea
A client is diagnosed with obsessive-compulsive disorder (OCD), and a nurse is planning care. Which of the following interventions should the nurse exclude from the care plan?
- A. Allowing the client to perform rituals initially
- B. Discouraging the client from washing their hands
- C. Monitoring for suicidal ideation
- D. Providing a structured schedule of activities
Correct Answer: C
Rationale: The correct answer is monitoring for suicidal ideation. When caring for a client with OCD, interventions should include allowing the client to perform rituals initially, setting limits on the time allowed for rituals, encouraging the client to verbalize feelings, and providing a structured schedule of activities. Monitoring for suicidal ideation is crucial in assessing the client's safety and mental health status, but it is not a direct intervention specific to managing OCD symptoms.
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A nurse is providing discharge instructions to a client who has been prescribed fluoxetine (Prozac). Which information should the nurse include?
- A. Take the medication with food to avoid stomach upset.
- B. Avoid drinking alcohol while taking this medication.
- C. Report any unusual side effects to the healthcare provider.
- D. It may take several weeks for this medication to take effect.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client diagnosed with schizophrenia is prescribed an antipsychotic medication. Which of the following side effects should the nurse not monitor for? Select all that apply.
- A. Tardive dyskinesia
- B. Neuroleptic malignant syndrome
- C. Orthostatic hypotension
- D. Hyperglycemia
Correct Answer: A
Rationale: The nurse should not monitor for tardive dyskinesia as it is a potential long-term side effect of antipsychotic medications. However, the nurse should monitor for neuroleptic malignant syndrome, orthostatic hypotension, and hyperglycemia as these are common side effects associated with antipsychotic medications. Tardive dyskinesia is characterized by involuntary movements of the face, tongue, and extremities and may develop after prolonged use of antipsychotic drugs.
In assessing a client with major depressive disorder, which of the following findings shouldn't the nurse expect?
- A. Anhedonia
- B. Hypersomnia
- C. Fatigue
- D. Flight of ideas
Correct Answer: D
Rationale: In major depressive disorder, common findings include anhedonia (loss of interest or pleasure), hypersomnia (excessive sleepiness), fatigue, and feelings of worthlessness. Flight of ideas, characterized by racing thoughts and rapid speech, is typically associated with bipolar disorder during manic episodes, not major depressive disorder.
Which of the following characteristics is not a feature of borderline personality disorder?
- A. Intense fear of abandonment
- B. Unstable relationships
- C. Impulsivity
- D. Grandiosity
Correct Answer: D
Rationale: Borderline personality disorder is characterized by an intense fear of abandonment, unstable relationships, impulsivity, and chronic feelings of emptiness. Grandiosity, which involves an inflated sense of self-importance, is typically associated with narcissistic personality disorder rather than borderline personality disorder.
A client diagnosed with schizophrenia is receiving discharge teaching. Which of the following instructions should the nurse exclude?
- A. Continue taking medications as prescribed
- B. Avoid all social interactions
- C. Report any side effects of medications to the healthcare provider
- D. Develop a daily routine
Correct Answer: B
Rationale: The nurse should exclude the instruction to 'Avoid all social interactions' when providing discharge teaching to a client with schizophrenia. It's important for individuals with schizophrenia to continue taking medications as prescribed, report any medication side effects to the healthcare provider, and develop a daily routine to promote stability. Social interactions, albeit with appropriate boundaries, can be beneficial for the client's well-being and integration into the community.