Nokea
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.
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The client tells the nurse, 'I thought my psychiatrist was the best doctor in the world. I thought he understood me completely. Now, I hate him! He doesn't understand me at all. He's just dumping me to go on a 2-week vacation.' The nurse assesses the client's description of feelings about the physician as evidence of the use of:
- A. Splitting
- B. Projective identification
- C. Isolation of affect
- D. Dissociation
Correct Answer: A
Rationale: The correct answer is A: Splitting. Splitting is a defense mechanism where a person sees things as all good or all bad, leading to extreme shifts in perception. In this case, the client initially viewed the psychiatrist as the best doctor but now hates him completely due to feeling abandoned. This sudden shift from idealization to devaluation is characteristic of splitting.
Choice B: Projective identification involves attributing one's own unacceptable feelings or traits onto another. This is not evident in the client's description.
Choice C: Isolation of affect refers to separating emotions from their source. The client is expressing strong emotions towards the psychiatrist, not isolating them.
Choice D: Dissociation involves a disruption in consciousness, memory, identity, or perception. The client is not displaying symptoms of dissociation in this scenario.
A nurse would assess for which feature in a patient diagnosed with bulimia nervosa?
- A. Introverted personality traits
- B. Abuse of diuretics and laxatives
- C. Disinterest in sexual activity
- D. Denial of hunger at all times
Correct Answer: B
Rationale: The correct answer is B because abuse of diuretics and laxatives is a common behavior in individuals with bulimia nervosa to control weight. This behavior is known as purging. Choice A is incorrect as personality traits vary among individuals with bulimia nervosa. Choice C is incorrect as disinterest in sexual activity is not a typical feature of this disorder. Choice D is incorrect as individuals with bulimia nervosa often experience episodes of binge eating, indicating they do experience hunger at times.
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.
Which nursing intervention has highest priority for a patient with bulimia nervosa?
- A. Assist the patient to identify triggers to binge eating.
- B. Provide remedial consequences for weight loss.
- C. Assess for signs of impulsive eating.
- D. Explore needs for health teaching.
Correct Answer: A
Rationale: The correct answer is A: Assist the patient to identify triggers to binge eating. The highest priority for a patient with bulimia nervosa is addressing the root cause of the behavior, which is often triggered by emotional or situational factors. By identifying triggers, the patient can learn to recognize and manage them effectively, ultimately reducing the frequency of binge eating episodes. This intervention focuses on addressing the underlying issue and promoting long-term recovery.
Summary:
B: Providing remedial consequences for weight loss is not the priority as the main concern is addressing the binge eating behavior.
C: Assessing for signs of impulsive eating is important, but identifying triggers takes precedence in addressing the behavior.
D: Exploring needs for health teaching may be relevant, but addressing triggers to binge eating is more immediate and crucial for managing bulimia nervosa.
A patient with schizophrenia has been stabilized in the Crisis Center and is about to be discharged. He will be living with his family, but the family knows nothing about the patient's illness, its treatment, or the role they can play in his recovery. Which activity would be most beneficial for the family to attend?
- A. Psychoanalytic group
- B. Psychoeducational group
- C. Individual counseling
- D. Family therapy
Correct Answer: B
Rationale: The correct answer is B: Psychoeducational group. This option is most beneficial as it will provide the family with education about schizophrenia, its treatment, and the role they can play in the patient's recovery. This will help the family better understand the illness, how to support the patient, and how to communicate effectively.
Explanation:
1. Psychoanalytic group (A) focuses on exploring unconscious thoughts and emotions, which may not be as practical or helpful for educating the family about schizophrenia.
2. Individual counseling (C) may not involve the family as a whole and may not provide the necessary education and support for the family unit.
3. Family therapy (D) could be beneficial, but psychoeducational group specifically targets providing knowledge and skills needed to support the patient's recovery, making it the most appropriate choice in this scenario.