Nokea
A client with schizophrenia is prescribed an antipsychotic medication. Which of the following side effects shouldn't the nurse monitor for?
- A. Tardive dyskinesia
- B. Decreased need for sleep
- C. Orthostatic hypotension
- D. Hyperglycemia
Correct Answer: B
Rationale: The correct answer is B, 'Decreased need for sleep.' While antipsychotic medications can cause side effects like tardive dyskinesia, orthostatic hypotension, and hyperglycemia, a decreased need for sleep is not a common side effect. It is important for the nurse to monitor the client for the known side effects of antipsychotic medications to ensure early detection and appropriate management.
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During an assessment, a nurse observes a client showing signs of moderate anxiety. Which symptom is not typically associated with moderate anxiety?
- A. Fidgeting
- B. Laughing inappropriately
- C. Palpitations
- D. Nail biting
Correct Answer: C
Rationale: When assessing a client with moderate anxiety, the nurse should anticipate signs such as fidgeting, laughing inappropriately, and nail biting. These behaviors are common manifestations of increased stress levels. Palpitations, on the other hand, are more commonly associated with severe anxiety or panic attacks. Other symptoms of severe anxiety may include restlessness, difficulty concentrating, muscle tension, and sleep disturbances.
Which of the following is not a potential side effect of electroconvulsive therapy (ECT)?
- A. Short-term memory loss
- B. Headache
- C. Confusion
- D. Tardive dyskinesia
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
When assessing a client with bipolar disorder who is experiencing a depressive episode, which of the following findings should the nurse not expect?
- A. Low energy
- B. Feelings of hopelessness
- C. Insomnia or hypersomnia
- D. Difficulty concentrating
Correct Answer: D
Rationale: In a client experiencing a depressive episode in bipolar disorder, common findings include low energy, feelings of hopelessness, insomnia or hypersomnia, and decreased appetite. Difficulty concentrating is more indicative of attention deficit disorders or cognitive impairment rather than a typical presentation of a depressive episode in bipolar disorder.
A client has been diagnosed with borderline personality disorder, and a nurse is providing care. Which intervention should the nurse implement to promote the client's safety?
- A. Implement a no-harm contract with the client.
- B. Monitor the client closely for signs of self-harm.
- C. Encourage the client to participate in recreational activities.
- D. Encourage the client to maintain a structured daily routine.
Correct Answer: A
Rationale: Implementing a no-harm contract is a crucial intervention for clients with borderline personality disorder as it helps establish an agreement between the client and the healthcare provider to abstain from self-harming behaviors. This contract aims to promote the client's safety by enhancing awareness and providing a structured approach in managing impulses and emotions.
Which of the following interventions should not be included in the care plan for a client with major depressive disorder?
- A. Encourage participation in activities
- B. Promote adequate nutrition and hydration
- C. Discourage verbalization of feelings
- D. Monitor for suicidal ideation
Correct Answer: C
Rationale: Interventions for a client with major depressive disorder should focus on promoting activities, adequate nutrition, hydration, and monitoring for suicidal ideation. Verbalizing feelings is a crucial part of therapy for clients with depression as it helps in processing emotions and seeking support. Therefore, discouraging verbalization of feelings is not appropriate and goes against therapeutic principles.