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A client with a diagnosis of schizophrenia is prescribed risperidone (Risperdal). Which statement by the client indicates a need for further teaching?
- A. I can stop taking this medication once I feel better.
- B. I need to avoid foods that are high in tyramine.
- C. I should avoid drinking alcohol while taking this medication.
- D. This medication may cause drowsiness, so avoid driving.
Correct Answer: A
Rationale: The correct answer is A. The statement 'I can stop taking this medication once I feel better' indicates a need for further teaching. Antipsychotic medications, like risperidone, should be taken consistently even when symptoms improve to prevent relapse. Choice B is incorrect because avoiding foods high in tyramine is unrelated to risperidone. Choice C is incorrect as avoiding alcohol is a standard precaution with many medications. Choice D is incorrect because being cautious about drowsiness and avoiding driving is a common safety measure associated with risperidone.
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An elderly female client with advanced dementia is admitted to the hospital with a fractured hip. The client repeatedly tells the staff, 'Take me home. I want my Mommy.' Which response is best for the nurse to provide?
- A. Orient the client to the time, place, and person.
- B. Tell the client that the nurse is there and will help her.
- C. Remind the client that her mother is no longer living.
- D. Explain the seriousness of her injury and need for hospitalization.
Correct Answer: B
Rationale: Those with dementia often refer to home or parents when seeking security and comfort. The nurse should use the techniques of 'offering self' and 'talking to the feelings' to provide reassurance (B). Clients with advanced dementia have permanent physiological changes in the brain (plaques and tangles) that prevent them from comprehending and retaining new information, so choices A, C, and D are likely to be of little use to this client and do not address the emotional needs expressed by the client. Option B acknowledges the client's feelings, offers support, and provides reassurance, which can help comfort the client during this distressing time.
What information should the nurse include in the client's teaching about starting a selective serotonin reuptake inhibitor (SSRI) for major depressive disorder?
- A. It may take several weeks for the medication to take effect.
- B. You can stop taking the medication once you feel better.
- C. Avoid foods high in tyramine while on this medication.
- D. You should expect an immediate improvement in mood.
Correct Answer: A
Rationale: The correct answer is A: "It may take several weeks for the medication to take effect." SSRIs typically take several weeks to reach their full effect, and it's important to set realistic expectations for the client. Choice B is incorrect because stopping the medication abruptly can lead to withdrawal symptoms and worsening of depression. Choice C is unrelated to SSRI therapy and pertains more to MAOIs. Choice D is incorrect as SSRIs do not provide immediate improvement in mood; rather, they require time to exert their therapeutic effects.
Two days after his last drink, a male alcoholic client becomes agitated and yells at his wife and children, 'Stay away from me!' His vital signs are elevated. What nursing diagnosis has the highest priority?
- A. High risk for social isolation.
- B. Altered parenting.
- C. Ineffective individual coping.
- D. High risk for injury.
Correct Answer: D
Rationale: The correct answer is 'High risk for injury.' The client's agitation, elevated vital signs, and aggressive behavior pose a threat to himself and his family. Addressing the risk for injury is the priority to ensure the safety of all individuals involved. Choices A, B, and C are not the highest priority in this scenario. 'High risk for social isolation' does not address the immediate physical safety concern. 'Altered parenting' and 'Ineffective individual coping' are important but not as urgent as the risk for injury in this situation.
The charge nurse is collaborating with the nursing staff about the plan of care for a client who is very depressed. What is the most important intervention to implement during the first 48 hours after the client's admission to the unit?
- A. Monitor appetite and observe intake during meals.
- B. Maintain safety in the client's environment.
- C. Provide ongoing, supportive contact.
- D. Encourage participation in activities.
Correct Answer: B
Rationale: The most critical intervention to implement during the first 48 hours after admitting a depressed client is to maintain safety (B). Depression increases the risk of suicide; hence ensuring a safe environment is the priority. While monitoring appetite (A), providing supportive contact (C), and encouraging participation in activities (D) are important aspects of care for a depressed client, ensuring safety takes precedence in the initial phase of admission.
A 65-year-old female client complains to the nurse that recently she has been hearing voices. What question should the nurse ask this client first?
- A. Do you have problems with hallucinations?
- B. Are you ever alone when you hear the voices?
- C. Has anyone in your family had hearing problems?
- D. Do you see things that others cannot see?
Correct Answer: B
Rationale: The nurse should first ask if the client is ever alone when she hears the voices. This question helps differentiate between potential auditory hallucinations and other causes like hearing loss. Choice A is not the best first question as it assumes the client is experiencing hallucinations without exploring other possibilities. Choice C is irrelevant to the immediate concern of hearing voices. Choice D pertains to visual hallucinations which are not described in the client's complaint of hearing voices.