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A client who received chlorpromazine (Thorazine) for 15 years to treat schizophrenia developed tardive dyskinesia as evidenced by tongue thrusting and chewing motions. The physician discontinued the chlorpromazine and prescribed Seroquel (quetiapine). As a result of this change, the nurse should carefully monitor for:
- A. Development of pseudoparkinsonism
- B. Development of dystonic reactions
- C. Improvement in tardive dyskinesia
- D. Worsening of anticholinergic symptoms
Correct Answer: C
Rationale: The correct answer is C: Improvement in tardive dyskinesia. Tardive dyskinesia is a side effect of long-term antipsychotic use, such as chlorpromazine. Quetiapine (Seroquel) is a second-generation antipsychotic with a lower risk of causing tardive dyskinesia. By discontinuing chlorpromazine and switching to quetiapine, the client is less likely to experience worsening of tardive dyskinesia symptoms. Monitoring for improvement in tardive dyskinesia is essential in this situation.
Choices A, B, and D are incorrect:
A: Development of pseudoparkinsonism is less likely with quetiapine compared to first-generation antipsychotics like chlorpromazine.
B: Dystonic reactions are acute side effects and are not typically associated with switching to quetiapine.
D: Anticholinergic symptoms are not directly related to tardive dyskinesia
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A rape victim tells the nurse, "I should not have been out on the street alone."Â Select the nurse's most helpful response.
- A. Rape can happen anywhere.
- B. Blaming yourself increases your anxiety and discomfort.
- C. You are right. You should not have been alone on the street at night.
- D. You feel as though this would not have happened if you had not been alone.
Correct Answer: D
Rationale: The correct answer is D because it acknowledges the victim's feelings without placing blame or judgment. By reflecting the victim's feelings back to them, the nurse validates their experience and shows empathy. This response encourages the victim to express their emotions and helps in building trust with the nurse.
Other choices are incorrect:
A: This choice does not address the victim's feelings of self-blame and does not provide the needed support.
B: While this choice acknowledges the negative impact of self-blame, it does not directly address the victim's statement.
C: This choice may be perceived as dismissive or blaming, which can further harm the victim's emotional well-being.
A patient tells the nurse, 'I can't go to any unit meetings because when I get in that room, everyone can hear my thoughts.' The nurse can correctly assess this symptom as:
- A. concrete thinking.
- B. loose associations.
- C. thought broadcasting.
- D. auditory hallucinations.
Correct Answer: C
Rationale: The correct answer is C: thought broadcasting. This is when a person believes that others can hear their thoughts. In this scenario, the patient's belief that everyone in the unit meetings can hear their thoughts aligns with the symptom of thought broadcasting. It is a common manifestation of certain psychiatric disorders like schizophrenia.
Choice A, concrete thinking, refers to literal thinking without abstract reasoning and is not applicable in this context. Choice B, loose associations, involves disorganized and illogical thought patterns, which are not evident in the patient's statement. Choice D, auditory hallucinations, refers to hearing voices when no external stimulus is present, which is different from the patient's belief that others can hear their thoughts.
The spouse of a man being treated with sertraline (Zoloft) calls to report that he had a grand mal seizure. Prior to the seizure, he had seemed confused and his forehead felt hot. The man does not have a seizure-disorder history. Which action should the nurse direct the spouse to take?
- A. Monitor the patient and notify the clinic if there are more seizures.
- B. Hold all medications and call 911 for transportation to the hospital.
- C. Hold tonight's sertraline and encourage him to drink more fluids.
- D. Administer an antipyretic drug to lower his fever and prevent seizures.
Correct Answer: B
Rationale: Step 1: The man had a grand mal seizure, confusion, and a hot forehead, which are signs of serotonin syndrome, a serious side effect of sertraline.
Step 2: The nurse should direct the spouse to hold all medications to prevent further serotonin syndrome symptoms.
Step 3: Calling 911 for immediate transportation to the hospital is crucial for prompt evaluation and treatment of the seizure and serotonin syndrome.
Step 4: This action ensures the man receives appropriate medical care to address the seizure and manage the potential serotonin syndrome.
Summary:
- Choice A is incorrect as monitoring the patient at home is not sufficient for a serious medical emergency like serotonin syndrome.
- Choice C is incorrect as simply holding tonight's sertraline and encouraging fluids does not address the immediate need for medical intervention.
- Choice D is incorrect as administering an antipyretic drug does not address the underlying cause of the seizure and confusion, which is serotonin syndrome.
Care planning requires that a nurse recognize that the dynamic focus directing a patient with anorexia nervosa is:
- A. managing weight gain.
- B. controlling personal stressors.
- C. maintaining a sense of control.
- D. avoiding social interactions.
Correct Answer: C
Rationale: Step 1: Anorexia nervosa is characterized by an intense fear of gaining weight and a distorted body image.
Step 2: Patients often use strict control over food intake as a way to cope with underlying emotional issues.
Step 3: Maintaining a sense of control is crucial in managing anorexia nervosa as it addresses the core psychological aspects driving the disorder.
Step 4: Managing weight gain (A) is not the primary focus as patients may resist gaining weight due to their fear.
Step 5: Controlling personal stressors (B) may be important but does not address the underlying issue of control related to food and body.
Step 6: Avoiding social interactions (D) does not address the core psychological need for control and can further isolate the patient.
A 14-year-old client on the eating disorders unit refuses to eat her meals and says to the nurse on the unit, 'You can't make me eat! There is nothing wrong with me.' The nurse will assess this as use of which defense mechanism?
- A. Repression.
- B. Rationalization.
- C. Sublimation.
- D. Denial.
Correct Answer: D
Rationale: The correct answer is D: Denial. Denial is a defense mechanism where an individual refuses to acknowledge reality to avoid discomfort. In this scenario, the client is denying the seriousness of their situation by refusing to eat and claiming there is nothing wrong. Repression (A) involves unconsciously blocking out unpleasant thoughts or feelings. Rationalization (B) is creating logical explanations to justify behavior. Sublimation (C) is redirecting negative impulses into positive behaviors. In this case, denial is the most fitting defense mechanism as the client is refusing to accept the reality of their eating disorder.