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A client with schizophrenia is being treated with haloperidol (Haldol) and begins to exhibit symptoms of tardive dyskinesia. What is the nurse's priority action?
- A. Continue the medication and monitor for worsening symptoms.
- B. Administer the next dose of haloperidol with food.
- C. Report the symptoms to the healthcare provider immediately.
- D. Educate the client about the side effects of haloperidol.
Correct Answer: C
Rationale: The correct answer is to report the symptoms to the healthcare provider immediately. Tardive dyskinesia is a serious side effect of antipsychotic medications, including haloperidol. Prompt reporting is crucial to evaluate the need for medication adjustment or change in treatment. Continuing the medication without intervention (choice A) can worsen the symptoms. Administering the next dose (choice B) is not appropriate when tardive dyskinesia is suspected. Educating the client (choice D) is important but not the priority when dealing with acute symptoms of tardive dyskinesia.
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A client with schizophrenia is experiencing auditory hallucinations. What is the most appropriate nursing intervention?
- A. Encourage the client to focus on reality-based activities.
- B. Tell the client that the voices are not real.
- C. Ask the client to describe the voices he hears.
- D. Encourage the client to interact with others who are not experiencing hallucinations.
Correct Answer: A
Rationale: The most appropriate nursing intervention for a client with schizophrenia experiencing auditory hallucinations is to encourage the client to focus on reality-based activities. This intervention helps redirect their attention away from hallucinations, promoting engagement with the environment. Choice B is incorrect as telling the client that the voices are not real may invalidate their experiences and worsen the therapeutic relationship. Choice C may increase the client's distress by focusing on the hallucinations. Choice D might not be helpful as interacting with others who are not experiencing hallucinations may not address the client's current needs.
A client who is being treated with lithium carbonate for bipolar disorder develops diarrhea, vomiting, and drowsiness. What action should the LPN/LVN take?
- A. Notify the healthcare provider immediately and prepare for administration of an antidote.
- B. Notify the healthcare provider of the symptoms prior to the next administration of the drug.
- C. Record the symptoms as normal side effects and continue administration of the prescribed dosage.
- D. Hold the medication and refuse to administer additional amounts of the drug.
Correct Answer: B
Rationale: When a client being treated with lithium carbonate for bipolar disorder develops symptoms like diarrhea, vomiting, and drowsiness, it could indicate lithium toxicity. The appropriate action for the LPN/LVN is to notify the healthcare provider immediately of these symptoms before the next administration of the drug. This prompt communication is crucial to ensure that the healthcare provider can assess the situation, adjust the treatment plan if necessary, and prevent potential complications associated with lithium toxicity. Option A is incorrect because administering an antidote should be based on the healthcare provider's assessment. Option C is incorrect as these symptoms are not normal side effects and could indicate a serious issue. Option D is incorrect because refusing to administer the drug without consulting the healthcare provider could delay necessary interventions.
A client with generalized anxiety disorder (GAD) is prescribed buspirone (BuSpar). The client asks how long it will take for the medication to start working. What is the nurse's best response?
- A. You should start feeling better within a few days.
- B. It may take 2 to 4 weeks before you notice an improvement.
- C. Buspirone works immediately to reduce anxiety symptoms.
- D. You will need to take this medication for at least a year.
Correct Answer: B
Rationale: The correct answer is B. Buspirone typically takes 2 to 4 weeks to become fully effective. It is essential to inform the client that it may take some time before they notice an improvement. Choice A is incorrect because buspirone does not work immediately. Choice C is also incorrect as buspirone does not provide immediate relief. Choice D is incorrect as it suggests a longer duration of treatment than necessary.
A female client in an acute care facility has been on antipsychotic medications for the past three days. Her psychotic behaviors have decreased and she has had no adverse reactions. On the fourth day, the client's blood pressure increases, she becomes pale and febrile, and demonstrates muscular rigidity. What action should the nurse initiate?
- A. Place the client on seizure precautions and monitor her frequently.
- B. Take the client's vital signs and notify the physician immediately.
- C. Describe the symptoms to the charge nurse and document them in the client's record.
- D. No action is required at this time as these are known side effects of her medications.
Correct Answer: B
Rationale: The correct action for the nurse to initiate is to take the client's vital signs and notify the physician immediately. These symptoms may indicate neuroleptic malignant syndrome, a rare but life-threatening reaction to antipsychotic medications, requiring immediate medical attention. Placing the client on seizure precautions and monitoring her frequently (Choice A) is not the most appropriate action in this situation. Describing the symptoms to the charge nurse and documenting them in the client's record (Choice C) delays prompt medical intervention. Choosing not to take any action (Choice D) is dangerous as the symptoms described suggest a serious condition that needs urgent evaluation and treatment.
An adult male client who was admitted to the mental health unit yesterday tells the nurse that microchips were planted in his head for military surveillance of his every move. Which response is best for the LPN/LVN to provide?
- A. You are in the hospital, and I am the nurse caring for you.
- B. It must be difficult for you to control your anxious feelings.
- C. Go to occupational therapy and start a project.
- D. You are not in a war area now; this is the United States.
Correct Answer: A
Rationale: The best response for the LPN/LVN to provide is option A: 'You are in the hospital, and I am the nurse caring for you.' This response is effective as it grounds the client in the present reality while also acknowledging the client's feelings. It shows acceptance of the client's experience without directly challenging the delusional belief, which can help build rapport and trust. Option B focuses on anxiety rather than validating the client's experience or addressing the delusion. Option C suggests an unrelated activity that may not be helpful in this situation. Option D attempts to correct the client's belief, which is not likely to be effective in managing delusional thoughts.