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A female client with depression attends a group and states that she sometimes misses her medication appointments because she feels very anxious about riding the bus. Which statement is the nurse's best response?
- A. Can your case manager take you to your appointments?
- B. Take your medication for anxiety before you ride the bus.
- C. Let's talk about what happens when you feel very anxious.
- D. What are some ways that you can cope with your anxiety?
Correct Answer: D
Rationale: Encouraging the client to discuss coping mechanisms for anxiety is a supportive approach that empowers the client to manage their symptoms. Choice A may not address the client's self-management and coping skills. Choice B suggests using anxiety medication before riding the bus, which may not be the most appropriate solution. Choice C acknowledges the anxiety but does not actively involve the client in finding solutions, unlike Choice D which promotes client empowerment and self-efficacy.
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A client with schizophrenia is being discharged with a prescription for risperidone (Risperdal). What is the most important information for the nurse to provide?
- A. You need to have regular blood tests while taking this medication.
- B. Report any muscle stiffness or unusual movements immediately.
- C. Avoid foods high in tyramine while taking this medication.
- D. This medication may cause weight loss.
Correct Answer: B
Rationale: The correct answer is B: "Report any muscle stiffness or unusual movements immediately." This information is crucial because muscle stiffness or unusual movements may indicate extrapyramidal symptoms (EPS), a potential side effect of risperidone that requires immediate attention. Choice A is less critical as regular blood tests are important but not as urgent as identifying EPS. Choice C is irrelevant as tyramine interactions are not associated with risperidone. Choice D is incorrect as weight gain is more common than weight loss with risperidone.
An elderly client was prescribed Ativan 1 mg three times a day to help calm her anxiety after her husband's death. The next day the client calls her daughter asking when she is picking her up to go to the graveside. The client says she has been walking up and down the driveway for the past hour waiting for her daughter. Noting the client's agitation, hyperactivity, and insistence, the daughter calls the nurse to report her mother's behavior. What should the nurse suspect?
- A. The client is manic and may need a sleeping pill
- B. The client is experiencing a medication interaction and should go to the ED
- C. The client is experiencing a paradoxical reaction to the Ativan and should stop the new medication immediately
- D. The client is overcome by grief and probably needs an antidepressant
Correct Answer: C
Rationale: A paradoxical reaction to Ativan, where the drug causes opposite effects such as increased agitation and hyperactivity, should prompt immediate cessation of the medication. In this scenario, the client was prescribed Ativan to help calm her anxiety, but instead, she is displaying symptoms of increased agitation and hyperactivity, indicating a paradoxical reaction. Choice A is incorrect because the symptoms described do not align with mania. Choice B is incorrect as there is no mention of a medication interaction. Choice D is incorrect as the symptoms are more indicative of a paradoxical reaction rather than overwhelming grief.
A 22-year-old male client is admitted to the emergency center following a suicide attempt. His records reveal that this is his third suicide attempt in the past two years. He is conscious, but does not respond to verbal commands for treatment. Which assessment finding should prompt the nurse to prepare the client for gastric lavage?
- A. He ingested the drug 3 hours prior to admission to the emergency center.
- B. The family reports that he took an entire bottle of acetaminophen (Tylenol).
- C. He is unresponsive to instructions and is unable to cooperate with emetic therapy.
- D. Those with repeated suicide attempts desire punishment to relieve their guilt.
Correct Answer: C
Rationale: The correct answer is C because the client's unresponsiveness and inability to cooperate with emetic therapy indicate the need for gastric lavage. Gastric lavage is a procedure used to remove toxic substances from the stomach in cases where the patient is unresponsive or unable to cooperate. Choice A is incorrect as the time of ingestion alone does not indicate the need for gastric lavage. Choice B, although indicating a significant overdose, does not directly necessitate gastric lavage. Choice D is incorrect as it provides information about the possible psychological motivation for repeated suicide attempts, but it is not directly related to the immediate need for gastric lavage in this scenario.
A client in a long-term care facility who has multiple sclerosis is embarrassed about the need to use a wheelchair and the muscle spasms that are readily visible in her legs. Which approach is therapeutic in assisting the client to cope?
- A. Keep the client in her room as much as possible
- B. Assist the client with all activities of daily living
- C. Tell the client that many of the people in the facility have these same sorts of problems
- D. Encourage and praise perseverance in performing ADLs, and assist the client to dress and groom daily
Correct Answer: D
Rationale: Encouraging and praising the client's perseverance in performing activities of daily living (ADLs) is therapeutic as it helps the client maintain a sense of normalcy and dignity, thus supporting their psychosocial well-being. This approach acknowledges the client's struggles while empowering them to maintain their independence and self-care. Choices A and C are incorrect as they do not address the client's emotional needs and may contribute to further isolation and distress. Choice B, while important, does not specifically address the client's feelings of embarrassment and the need for emotional support.
The nurse is caring for a client who received the first-time electroconvulsive therapy (ECT) a half hour ago. Which action should the nurse implement first?
- A. Offer oral fluids.
- B. Monitor vital signs.
- C. Evaluate ECT effectiveness.
- D. Encourage group participation.
Correct Answer: B
Rationale: After a client receives electroconvulsive therapy (ECT), the nurse's priority should be to monitor vital signs. This is important to ensure the client's physical stability and detect any immediate complications post-procedure. Offering oral fluids, evaluating ECT effectiveness, and encouraging group participation are all important aspects of care but monitoring vital signs takes precedence in the immediate post-ECT period.