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A female client is admitted to the psychiatric unit with a diagnosis of anorexia nervosa. What is the priority nursing intervention?
- A. Monitor the client's vital signs regularly.
- B. Encourage the client to participate in group therapy.
- C. Offer the client frequent, high-calorie snacks.
- D. Weigh the client daily at the same time.
Correct Answer: D
Rationale: The correct answer is to weigh the client daily at the same time. Daily weights are crucial in monitoring the client's nutritional status and guiding treatment for weight restoration in anorexia nervosa. Monitoring vital signs is important but weighing the client daily takes precedence in this situation. Encouraging group therapy and offering high-calorie snacks are important aspects of treatment but do not take priority over monitoring the client's weight.
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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.
A client with bipolar disorder, manic phase, is admitted to the psychiatric unit. Which meal is most appropriate for this client?
- A. Spaghetti and meatballs
- B. Chicken salad sandwich
- C. Steak and potatoes
- D. Hamburger and fries
Correct Answer: B
Rationale: A chicken salad sandwich (B) is the most appropriate choice as it is easy to eat on the go, which is important for a client in the manic phase who may have difficulty sitting still for a meal. Spaghetti and meatballs (A) and steak and potatoes (C) require more time and effort to eat, which may be challenging for a client experiencing mania. While hamburger and fries (D) could be an option, a chicken salad sandwich is a healthier and more manageable choice, considering the client's potential hyperactive state.
At the first meeting of a group of older adults at a daycare center for the elderly, the nurse asks one of the members what kinds of things she would like to do with the group. The older woman shrugs her shoulders and says, 'You tell me, you're the leader.' What is the best response for the nurse to make?
- A. 'Yes, I am the leader today. Would you like to be the leader tomorrow?'
- B. 'Yes, I will be leading this group. What would you like to accomplish during this time?'
- C. 'Yes, I have been assigned to be the leader of this group. I will be here for the next six weeks.'
- D. 'Yes, I am the leader. You seem angry about not being the leader yourself.'
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A 20-year-old female client with schizophrenia is scheduled to receive risperidone (Risperdal) 2mg at bedtime. When the nurse attempts to administer the medication, the client states, 'I am not going to take that medicine, and you can't make me.' What action should the nurse take?
- A. Administer the medication via a nasogastric tube.
- B. Substitute an injectable form of the medication.
- C. Encourage the client to take the medicine because it will help her sleep.
- D. Document in the client's record that the medication was refused.
Correct Answer: D
Rationale: In this scenario, the correct action for the nurse to take is to respect the client's autonomy and decision-making capacity. It's crucial to document the medication refusal accurately in the client's record. Administering the medication via a nasogastric tube or substituting it with an injectable form would violate the client's right to refuse treatment and should only be considered in extreme cases after consulting with the healthcare team. Encouraging the client to take the medication because it will help her sleep disregards her autonomy and choice in the matter.
A female client refuses to take an oral hypoglycemic agent because she believes that the drug is being administered as part of an elaborate plan by the Mafia to harm her. Which nursing intervention is most important to include in this client's plan of care?
- A. Reassure the client that no one will harm her while she is in the hospital.
- B. Ask the healthcare provider to give the client the medication.
- C. Explain the importance of taking the diabetic medication.
- D. Reassess the client's mental status for thought processes and content.
Correct Answer: D
Rationale: Reassessing the client's mental status is the most important intervention as it is crucial to address the client's delusional thinking. By assessing the client's thought processes and content, the nurse can gain insight into the client's beliefs and tailor interventions accordingly. Reassuring the client that no harm will come to her, asking the healthcare provider to give the medication, or simply explaining the importance of taking the medication may not effectively address the underlying issue of delusional beliefs.