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A client with schizophrenia is prescribed risperidone. Which of the following should the nurse monitor for as an adverse effect of this medication?
- A. Increased blood pressure
- B. Weight gain
- C. Excessive salivation
- D. Bradycardia
Correct Answer: B
Rationale: The correct answer is B: Weight gain. Risperidone, an atypical antipsychotic, is known to cause metabolic side effects such as weight gain. This occurs due to its effects on increasing appetite and altering metabolism. Monitoring weight regularly is crucial to detect and manage this adverse effect to prevent complications like diabetes and cardiovascular issues. Increased blood pressure (A) is not a common adverse effect of risperidone. Excessive salivation (C) is more commonly associated with medications like clozapine. Bradycardia (D) is not a typical side effect of risperidone.
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A nurse is admitting a client who has schizophrenia. The client states, "I'm hearing voices." Which of the following responses is the priority for the nurse to state?
- A. "What are the voices telling you?"
- B. "I realize the voices are real to you, but I don't hear anything."
- C. "Have you taken your medication today?"
- D. "How long have you been hearing the voices?"
Correct Answer: A
Rationale: The correct answer is A: "What are the voices telling you?" This response demonstrates active listening, assesses the content of the hallucinations, and helps the nurse understand the client's experience. It allows for further assessment and intervention planning. Choice B dismisses the client's experience, choice C focuses on medication compliance rather than addressing the immediate concern, and choice D addresses the duration of the hallucinations but doesn't address the current situation.
A nurse in an acute mental health care facility is prioritizing care for multiple clients. Which of the following clients should the nurse see first?
- A. A client who has narcissistic personality disorder and is mocking others during group therapy
- B. A client who has obsessive-compulsive disorder and is upset about a change in daily routine
- C. A client who has depressive disorder and requires assistance with ADLs
- D. A client who is taking clozapine to treat schizophrenia and reports a sore throat
Correct Answer: D
Rationale: The correct answer is D. The nurse should see the client taking clozapine first due to the potential side effect of agranulocytosis, which can manifest as a sore throat. This is a serious adverse effect that requires immediate attention to prevent complications. The other clients do not present with urgent or life-threatening issues. A: Narcissistic behavior is disruptive but not a medical emergency. B: Upset about a routine change is distressing but does not pose a physical health risk. C: Assistance with ADLs is important but not immediately life-threatening. Therefore, prioritizing the client on clozapine with a sore throat is crucial to ensure timely intervention and prevent serious complications.
A home health nurse is planning care for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?
- A. Replace the carpet with hardwood floors.
- B. Encourage physical activity prior to bedtime.
- C. Wear clothing with zippers instead of buttons.
- D. Place locks at the tops of exterior doors.
Correct Answer: D
Rationale: The correct answer is D: Place locks at the tops of exterior doors. This is important for the safety of a client with Alzheimer's disease who may wander. Placing locks at the tops of doors can prevent the client from easily opening them and wandering off, which is a common behavior in Alzheimer's patients.
A: Replacing carpet with hardwood floors may not directly address the safety concern of wandering.
B: Encouraging physical activity prior to bedtime may help with sleep but does not address the safety issue of wandering.
C: Wearing clothing with zippers instead of buttons may be easier for the client to manage, but it does not address the safety concern of wandering.
Summary: The key consideration in caring for a client with Alzheimer's disease is ensuring their safety, particularly in preventing wandering, which is why placing locks at the tops of exterior doors is the most appropriate action.
A nurse is assessing a client who has major depressive disorder. Which of the following findings should the nurse expect? (Select all that apply)
- A. Anhedonia
- B. Insomnia
- C. Weight gain
- D. Flight of ideas
- E. Feelings of worthlessness
Correct Answer: A,B,E
Rationale: The correct answers are A, B, and E. Anhedonia is a key feature of major depressive disorder characterized by the inability to feel pleasure. Insomnia commonly occurs due to disrupted sleep patterns. Feelings of worthlessness are typical in depression due to negative self-perception. Weight gain is less common in major depressive disorder, typically weight loss is more prevalent. Flight of ideas is not a typical finding in major depressive disorder, as it is more associated with manic episodes in bipolar disorder.
A nurse is working with a client who has an anxiety disorder and is in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase?
- A. We should discuss resources to implement in your daily life.
- B. Let me show you simple relaxation exercises to manage stress.
- C. We should establish our roles in the initial session.
- D. Let's talk about how you can change your response to stress.
Correct Answer: C
Rationale: The correct answer is C: "We should establish our roles in the initial session." During the orientation phase of the therapeutic relationship, it is crucial to clarify the roles of both the nurse and the client to establish boundaries and expectations. This helps set the foundation for a trusting and effective therapeutic alliance. Discussing resources (A) and relaxation exercises (B) are important but typically occur later in the relationship. Talking about changing responses to stress (D) may be premature in the orientation phase. The other choices are not relevant to the specific goal of the orientation phase, which is to define roles and expectations.