Nokea
A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The RN also determines that the client is homeless and is exhibiting suspiciousness. The client's plan of care should include what priority problem?
- A. Acute confusion.
- B. Ineffective community coping.
- C. Disturbed sensory perception.
- D. Self-care deficit.
Correct Answer: A
Rationale: Acute confusion is the priority problem as it directly affects the client's ability to process information and make safe decisions. In this scenario, the client's disorientation, disorganization, and confusion indicate an immediate cognitive issue that requires attention to ensure her safety and stability. Choices B, C, and D are not the priority problems in this case. Ineffective community coping, disturbed sensory perception, and self-care deficit, while important, are secondary to the client's acute confusion, which poses an immediate risk to her well-being.
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A client with schizophrenia is prescribed olanzapine (Zyprexa). What is the most important side effect for the nurse to monitor?
- A. Hypotension
- B. Weight gain
- C. Dry mouth
- D. Tachycardia
Correct Answer: B
Rationale: The correct answer is B: Weight gain. Olanzapine (Zyprexa) is known to cause significant weight gain in patients. This side effect is crucial to monitor because it can lead to metabolic syndrome, diabetes, and cardiovascular issues. Monitoring the client's weight regularly and providing appropriate dietary guidance is essential. Hypotension (choice A), dry mouth (choice C), and tachycardia (choice D) are not commonly associated with olanzapine use and are not the primary side effects to monitor in this case.
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.
A 46-year-old female client has been on antipsychotic neuroleptic medication for the past three days. She has had a decrease in psychotic behavior and appears to be responding well to the medication. On the fourth day, the client's blood pressure increases, she becomes pale and febrile, and demonstrates muscular rigidity. Which action will the nurse initiate?
- A. Place the client on seizure precautions and monitor closely.
- B. Immediately transfer the client to the ICU.
- C. Report the symptoms to the charge nurse and document in the client's chart.
- D. No action is required at this time as these are known side effects of such medications.
Correct Answer: B
Rationale: These symptoms are indicative of neuroleptic malignant syndrome (NMS), which is a severe and life-threatening reaction to neuroleptic drugs. The major symptoms include fever, rigidity, autonomic instability, and encephalopathy. Respiratory failure, cardiovascular collapse, arrhythmias, and/or renal failure can lead to death. This is an emergency situation requiring immediate critical care, thus the correct action is to transfer the client to the ICU (B). Seizure precautions (A) are not relevant in this scenario. Merely describing the symptoms to the charge nurse and documenting them (C) or taking no action assuming these are common side effects (D) fail to address the critical nature of the situation and the urgency of immediate intervention.
A nurse determines that the wife of an alcoholic client is benefitting from attending an Al-Anon group when the nurse hears the wife say:
- A. I no longer feel that I deserve the meetings my husband inflicts on me.
- B. My attendance at the meetings has helped me to see that I provoke my husband's violence.
- C. I enjoy attending the meetings because they get me out of the house and away from my husband.
- D. I can tolerate my husband's destructive behaviors now that I know they are common with alcoholics.
Correct Answer: A
Rationale: Choice A is the correct answer as the statement indicates the wife understands that her husband's behavior is not her fault and is benefitting from the group support. Choice B is incorrect as it suggests self-blame rather than recognizing the husband's responsibility. Choice C is incorrect as the benefit is related to emotional support and understanding, not just getting away from the husband. Choice D is incorrect as tolerating destructive behaviors is not a healthy outcome of attending support groups.
A nurse working in a psychiatric unit is assessing a client who appears to be responding to internal stimuli. The client is laughing and talking to himself. What is the nurse's best initial response?
- A. Approach the client and ask if he is hearing voices.
- B. Ignore the behavior as it is common in psychiatric settings.
- C. Encourage the client to express his thoughts verbally.
- D. Observe the client's behavior from a distance.
Correct Answer: A
Rationale: Approaching the client and asking if he is hearing voices is the best initial response by the nurse. This action can help assess the situation and determine if the client is experiencing hallucinations that may require immediate intervention. Choice B is incorrect because ignoring the behavior could lead to missing important signs of distress or potential risks. Choice C may not address the immediate concern of assessing for hallucinations. Choice D is also not ideal as observing from a distance may not provide the necessary information for immediate assessment and intervention.