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A client with schizophrenia is prescribed an antipsychotic medication. Which of the following side effects should the nurse monitor for? Select one that does not apply.
- A. Tardive dyskinesia
- B. Neuroleptic malignant syndrome
- C. Mindfulness meditation
- D. Hyperglycemia
Correct Answer: C
Rationale: The correct answer is C, 'Mindfulness meditation.' Side effects of antipsychotic medications include tardive dyskinesia, neuroleptic malignant syndrome, orthostatic hypotension, and hyperglycemia. Mindfulness meditation is not a side effect of antipsychotic medications. Choices A, B, and D are all potential side effects of antipsychotic medications. Tardive dyskinesia is a movement disorder characterized by repetitive, involuntary movements. Neuroleptic malignant syndrome is a rare but life-threatening reaction to antipsychotic medication. Hyperglycemia can occur as a side effect of some antipsychotic medications, particularly the second-generation ones.
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A client is being assessed by a nurse after being diagnosed with anorexia nervosa. Which of the following findings should the nurse expect?
- A. Weight gain and increased appetite
- B. Lanugo on the face and back
- C. Increased body temperature and tachycardia
- D. Hyperactivity and distractibility
Correct Answer: B
Rationale: In anorexia nervosa, individuals often develop lanugo, fine soft hair, on the face and back. This is a physiological response to the body's attempt to conserve heat due to a lack of subcutaneous fat. It is a common physical finding in clients with anorexia nervosa and can be a sign of severe malnutrition. Choices A, C, and D are incorrect because weight gain and increased appetite, increased body temperature and tachycardia, and hyperactivity and distractibility are not typically associated with anorexia nervosa. In fact, weight loss, decreased appetite, hypothermia, and bradycardia are more commonly seen in individuals with anorexia nervosa.
A client is being taught relaxation techniques to manage anxiety. Which of the following techniques should be included in the teaching? Select one that does not apply.
- A. Deep breathing exercises
- B. Progressive muscle relaxation
- C. Mindfulness meditation
- D. Cognitive restructuring
Correct Answer: D
Rationale: Relaxation techniques commonly used to manage anxiety include deep breathing exercises, progressive muscle relaxation, mindfulness meditation, and guided imagery. Cognitive restructuring, on the other hand, is a cognitive-behavioral technique used to challenge and change negative thought patterns, not specifically a relaxation technique. Therefore, choice D, cognitive restructuring, does not apply to relaxation techniques for managing anxiety.
A nurse is providing education to the family of a client who has been diagnosed with major depressive disorder. Which of the following instructions should the nurse include?
- A. Encourage the client to avoid caffeine.
- B. Encourage the client to participate in physical activity.
- C. Encourage the client to express their feelings.
- D. Encourage the client to avoid isolation.
Correct Answer: D
Rationale: The nurse should instruct the family to encourage the client to avoid isolation. Social support and interaction are crucial for individuals with major depressive disorder as it can help in improving mood, reducing feelings of loneliness, and providing a sense of belonging and support. Choices A, B, and C are not the most appropriate instructions for a client with major depressive disorder. While avoiding caffeine can be beneficial for some individuals with anxiety or sleep issues, it is not a primary intervention for major depressive disorder. Encouraging physical activity and expressing feelings are important aspects of managing depression, but avoiding isolation is more critical to address first.
A client has been prescribed lithium for the treatment of bipolar disorder. Which of the following instructions should the nurse include?
- A. Avoid driving until you know how the medication affects you.
- B. Take the medication with food to prevent stomach upset.
- C. You may experience mild nausea when initiating the medication.
- D. Do not double the next dose if you miss one.
Correct Answer: A
Rationale: The correct instruction for the nurse to provide is to advise the client to avoid driving until they know how the medication affects them. Lithium can lead to side effects like dizziness and drowsiness, which could impair one's ability to drive safely. Choice B is incorrect because lithium is usually taken on an empty stomach. Choice C may be true but is not as critical as the potential side effects affecting driving. Choice D is important but not as immediate as ensuring the client's safety while driving.
A client with obsessive-compulsive disorder (OCD) tells the nurse, 'I know my behavior is unreasonable, but I can't help it.' What response should the nurse provide?
- A. Your behavior is part of your illness, and it is important to work on changing it.
- B. It is important to understand why you feel the need to perform these behaviors.
- C. Let's figure out a way for you to control these behaviors.
- D. It sounds like you are feeling powerless to change your behavior.
Correct Answer: D
Rationale: The nurse should acknowledge the client's awareness of the irrationality of their behavior and the feeling of powerlessness to change it. By reflecting the client's feelings, the nurse validates them and opens a discussion on strategies to manage the behavior effectively. Empathy and understanding are key in supporting clients with OCD. Choice A is incorrect because it focuses more on changing the behavior rather than acknowledging the client's feelings. Choice B is incorrect as it does not directly address the client's sense of powerlessness. Choice C is incorrect as it doesn't validate the client's feelings of being unable to control the behaviors.