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A client with schizophrenia is being treated with risperidone (Risperdal). The nurse notices that the client has a shuffling gait and tremors. What is the nurse's priority action?
- A. Administer a PRN dose of an anticholinergic medication.
- B. Document the findings and continue to monitor the client.
- C. Assess the client's blood glucose level.
- D. Notify the healthcare provider immediately.
Correct Answer: A
Rationale: A shuffling gait and tremors may indicate extrapyramidal side effects (EPS) from risperidone. The nurse's priority action should be to administer an anticholinergic medication as it can help alleviate these symptoms associated with EPS. Documenting the findings and monitoring the client (Choice B) are important but addressing the immediate symptoms takes precedence. Assessing the client's blood glucose level (Choice C) is not directly related to the observed symptoms of shuffling gait and tremors. While notifying the healthcare provider (Choice D) is important, it is not the priority action when dealing with EPS symptoms.
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The RN is preparing to administer a prescribed dose of haloperidol (Haldol) to a client with schizophrenia. The client begins to exhibit muscle rigidity, fever, and altered mental status. What action should the RN take first?
- A. Administer the haloperidol as prescribed.
- B. Monitor the client's vital signs closely.
- C. Hold the medication and notify the healthcare provider.
- D. Give the client an antipyretic for the fever.
Correct Answer: C
Rationale: Muscle rigidity, fever, and altered mental status are symptoms of neuroleptic malignant syndrome (NMS), a potentially life-threatening reaction to antipsychotic medications. The RN should hold the medication and notify the healthcare provider immediately. Option A is incorrect because administering more of the medication can worsen the symptoms. Option B is not the first priority when the client is experiencing symptoms of NMS. Option D is incorrect as addressing the fever alone does not address the underlying issue of NMS caused by haloperidol.
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.
The LPN/LVN is caring for a client who has been prescribed a monoamine oxidase inhibitor (MAOI) for depression. Which statement by the client indicates a need for further teaching?
- A. I need to avoid foods that are high in tyramine, like aged cheese and cured meats.
- B. I should take this medication with food to avoid nausea.
- C. I can drink alcohol in moderation while taking this medication.
- D. I can stop taking this medication once I feel better.
Correct Answer: C
Rationale: The statement 'I can drink alcohol in moderation while taking this medication' indicates a need for further teaching because alcohol consumption can have dangerous interactions with MAOIs. MAOIs can interact with alcohol to cause a hypertensive crisis, which can be life-threatening. Choices A and B are correct statements as avoiding tyramine-rich foods and taking the medication with food can help prevent adverse effects. Choice D is incorrect because abruptly stopping an antidepressant medication like an MAOI can lead to withdrawal symptoms and a relapse of depression.
A client with schizophrenia is being treated with clozapine (Clozaril). What is the most important laboratory test for the LPN/LVN to monitor?
- A. White blood cell count.
- B. Liver function tests.
- C. Blood glucose levels.
- D. Platelet count.
Correct Answer: A
Rationale: The most important laboratory test for an LPN/LVN to monitor for a client with schizophrenia being treated with clozapine is the white blood cell count. Clozapine treatment is associated with a risk of agranulocytosis, a severe drop in white blood cells, which can be life-threatening. Monitoring the white blood cell count regularly helps to detect this adverse effect early. Liver function tests (Choice B) are important to monitor with some antipsychotic medications but are not the most crucial for clozapine. Blood glucose levels (Choice C) are more relevant for monitoring in clients on medications like atypical antipsychotics that can cause metabolic side effects. Platelet count (Choice D) is not typically affected by clozapine therapy and is not the most important test to monitor in this case.
A nurse determines that the wife of an alcoholic client is benefitting from attending an Al-Anon group when the nurse hears the wife say:
- A. I no longer feel that I deserve the meetings my husband inflicts on me.
- B. My attendance at the meetings has helped me to see that I provoke my husband's violence.
- C. I enjoy attending the meetings because they get me out of the house and away from my husband.
- D. I can tolerate my husband's destructive behaviors now that I know they are common with alcoholics.
Correct Answer: A
Rationale: Choice A is the correct answer as the statement indicates the wife understands that her husband's behavior is not her fault and is benefitting from the group support. Choice B is incorrect as it suggests self-blame rather than recognizing the husband's responsibility. Choice C is incorrect as the benefit is related to emotional support and understanding, not just getting away from the husband. Choice D is incorrect as tolerating destructive behaviors is not a healthy outcome of attending support groups.