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A client with schizophrenia receiving haloperidol (Haldol) has a stiff, mask-like facial expression and difficulty speaking. What is the nurse's priority action?
- A. Administer a PRN dose of lorazepam (Ativan).
- B. Encourage the client to perform facial exercises.
- C. Notify the healthcare provider of possible extrapyramidal symptoms (EPS).
- D. Document the findings and continue to monitor the client.
Correct Answer: C
Rationale: The correct answer is to notify the healthcare provider of possible extrapyramidal symptoms (EPS). The symptoms described, such as a stiff, mask-like facial expression and difficulty speaking, are indicative of EPS, which can be a serious side effect of haloperidol. It is crucial to involve the healthcare provider immediately to address these symptoms. Administering a PRN dose of lorazepam (Choice A) is not the priority in this situation, as it does not address the underlying cause of EPS. Encouraging the client to perform facial exercises (Choice B) is not appropriate and may not effectively manage EPS. Documenting the findings and continuing to monitor the client (Choice D) is important but not the priority when potential EPS is present; immediate action by notifying the healthcare provider is essential.
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A woman brings her 48-year-old husband to the outpatient psychiatric unit and describes his behavior to the admitting nurse. She states that he has been sleepwalking, cannot remember who he is, and exhibits multiple personalities. The nurse knows that these behaviors are often associated with
- A. dissociative disorder.
- B. obsessive-compulsive disorder.
- C. panic disorder.
- D. post-traumatic stress disorder.
Correct Answer: A
Rationale: The correct answer is A: dissociative disorder. Sleepwalking, amnesia, and multiple personalities are examples of detaching emotional conflict from one's consciousness, which is the definition of a dissociative disorder. Obsessive-compulsive disorder (B) is characterized by persistent, recurrent intrusive thoughts or urges (obsessions) and compulsions. Panic disorder (C) is characterized by acute attacks of anxiety. Post-traumatic stress disorder (D) involves re-experiencing psychologically distressing events.
An outpatient clinic that has been receiving haloperidol (Haldol) for 2 days develops muscular rigidity, altered consciousness, a temperature of 103, and trouble breathing on day 3. The LPN/LVN interprets these findings as indicating which of the following?
- A. Neuroleptic Malignant Syndrome
- B. Tardive dyskinesia
- C. Extrapyramidal adverse effects
- D. Drug-induced parkinsonism
Correct Answer: A
Rationale: Neuroleptic Malignant Syndrome (NMS) is a life-threatening condition characterized by hyperthermia, muscle rigidity, altered consciousness, and autonomic dysregulation. It is a rare but serious side effect of antipsychotic medications like haloperidol (Haldol). NMS requires immediate intervention, including discontinuation of the offending medication and supportive care. Tardive dyskinesia (Choice B) is a different condition characterized by involuntary movements of the face and extremities that can occur with long-term antipsychotic use. Extrapyramidal adverse effects (Choice C) encompass a range of movement disorders like dystonia, akathisia, and parkinsonism that can result from antipsychotic medications, but they do not present with hyperthermia and altered consciousness as in NMS. Drug-induced parkinsonism (Choice D) is a form of parkinsonism caused by certain medications, but it typically presents with symptoms similar to Parkinson's disease, such as tremor, bradykinesia, and rigidity, without the severe hyperthermia and autonomic dysregulation seen in NMS.
The nurse is planning the care for a 32-year-old male client with acute depression. Which nursing intervention would be best in helping this client deal with his depression?
- A. Ensure that the client's day is filled with group activities.
- B. Assist the client in exploring feelings of shame, anger, and guilt.
- C. Allow the client to initiate and determine activities of daily living.
- D. Encourage the client to explore the rationale for his depression.
Correct Answer: B
Rationale: Assisting the client in exploring feelings of shame, anger, and guilt (B) is the most appropriate intervention for acute depression as it helps address core emotions that may be contributing to the condition. Focusing on these emotions can aid the client in processing and coping with their feelings. Ensuring that the client's day is filled with group activities (A) might overwhelm the client, as they may not be ready for social interactions during this sensitive time. Allowing the client to initiate and determine activities of daily living (C) is more suitable for chronic cases where the client needs to regain autonomy. Encouraging the client to explore the rationale for his depression (D) is less effective in acute cases, as the focus should be on immediate emotional support and understanding rather than cognitive analysis.
The nurse asks a female client with borderline personality disorder, 'How do you feel about your children not coming to visit this weekend?' The client looks out the window and replies, 'I really don't care.' Which response is best for the nurse to provide?
- A. I noticed you were looking out the window when discussing your feelings.
- B. I think you're lying and it bothers you that your children aren't coming.
- C. I think you should discuss your children not coming in the group meeting.
- D. Why do you think your children didn't want to come visit you this weekend?
Correct Answer: A
Rationale: Acknowledging the client's non-verbal behavior, such as looking out the window, demonstrates active listening and provides the client with an opportunity to explore their feelings further. Choice B is incorrect as it accuses the client of lying without any evidence, which can damage the therapeutic relationship. Choice C is inappropriate as it dismisses the client's feelings and suggests a group discussion without addressing the client's emotions directly. Choice D is also incorrect as it focuses on the children's actions rather than the client's feelings, missing an opportunity for therapeutic communication.
How should the RN respond to the mother?
- A. Ask the mother if she has ever thought about harming herself or her child.
- B. Reassure the mother that her child will achieve some growth and development milestones.
- C. Determine if the mother has other children who do not have developmental disabilities.
- D. Encourage the mother to write her thoughts and feelings in a journal.
Correct Answer: A
Rationale: The correct response is to ask the mother if she has ever thought about harming herself or her child. This is crucial to assess for suicidal or homicidal thoughts, ensuring the safety of both the mother and the child. Reassuring the mother about achieving some milestones may not address her immediate emotional distress. Inquiring about other children's developmental status is not the priority when safety concerns are present. While journaling can be therapeutic, in this situation, addressing safety takes precedence.