Nokea
A male client is admitted to the psychiatric unit for recurrent negative symptoms of chronic schizophrenia and medication adjustment of risperidone (Risperdal). When the client walks to the nurse’s station in a laterally contracted position, he states that something has made his body contort into a monster. What action should the nurse take?
- A. Medicate the client with the prescribed antipsychotic thioridazine (Mellaril)
- B. Offer the client a prescribed physical therapy hot pack for muscle spasms.
- C. Administer the prescribed anticholinergic benztropine (Cogentin) for dystonia.
- D. Direct client to occupational therapy to distract him from somatic complaints.
Correct Answer: C
Rationale: The correct action is to administer the prescribed anticholinergic benztropine (Cogentin) for dystonia. Dystonia is a side effect of antipsychotic medications like risperidone and can present as abnormal muscle contractions or postures. Benztropine is commonly used to manage dystonia by blocking excess acetylcholine in the brain. This helps to alleviate the muscle spasms and contractions that the client is experiencing. Mediating with thioridazine may not be appropriate as it is not the prescribed medication and may not effectively address the dystonia. Offering a hot pack for muscle spasms might provide temporary relief but does not address the underlying cause of dystonia. Directing the client to occupational therapy or distracting him may not effectively manage the dystonia symptoms. Administering benztropine is the most appropriate action to address the client's physical symptoms and improve his comfort and well-being.
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To provide effective care for the patient diagnosed with schizophrenia, the nurse should frequently assess for which associated condition? Select all that apply.
- A. Alcohol use disorder
- B. Major depressive disorder
- C. Stomach cancer
- D. Polydipsia
Correct Answer: A
Rationale: The correct answer is A: Alcohol use disorder. Patients with schizophrenia are at higher risk for co-occurring substance use disorders, including alcohol use disorder. Assessing for alcohol use is crucial as it can worsen symptoms and interfere with treatment. Major depressive disorder (B) is a common comorbidity but is not specific to schizophrenia. Stomach cancer (C) is not directly associated with schizophrenia. Polydipsia (D), excessive thirst, can be seen in schizophrenia due to medication side effects but is not a primary associated condition.
Kyle, a patient with schizophrenia, began to take the first-generation antipsychotic haloperidol (Haldol) last week. One day you find him sitting very stiffly and not moving. He is diaphoretic, and when you ask if he is okay he seems unable to respond verbally. His vital signs are: BP 170/100, P 110, T 104.2°F. What is the priority nursing intervention? Select all that apply.
- A. Hold his medication and contact his prescriber.
- B. Wipe him with a washcloth wet with cold water or alcohol.
- C. Administer a medication such as benztropine IM to correct this dystonic reaction.
- D. Reassure him that although there is no treatment for his tardive dyskinesia, it will pass.
Correct Answer: C
Rationale: The correct answer is C: Administer a medication such as benztropine IM to correct this dystonic reaction. The patient is exhibiting symptoms of acute dystonia, a side effect of haloperidol. Benztropine is a commonly used anticholinergic medication that can quickly reverse these symptoms. It is important to address this promptly to prevent further complications. Holding the medication and contacting the prescriber (choice A) can be done after addressing the acute symptoms. Wiping the patient with cold water or alcohol (choice B) may provide temporary relief but does not address the underlying cause. Reassuring the patient about tardive dyskinesia (choice D) is incorrect as the current symptoms are not related to tardive dyskinesia.
What assessment question will provide the nurse with information regarding the effects of a woman’s circadian rhythms on her quality of life?
- A. I notice that you frowned and avoided eye contact just now. Don’t you feel well?
- B. Does your heart ever seem to skip a beat?
- C. When was the last time you had a fever?
- D. Do you have problems urinating?
- E. How much sleep do you usually get each night?
Correct Answer: E
Rationale: The correct answer is E: How much sleep do you usually get each night? This question directly addresses the effects of circadian rhythms on the woman's quality of life as sleep patterns are regulated by these rhythms. By understanding her typical sleep duration, the nurse can assess if her circadian rhythms are impacting her quality of life. Choices A, B, C, and D do not specifically address circadian rhythms and their effects. A focuses on general well-being, B on cardiac issues, C on fever, and D on urinary problems. These options do not provide relevant information about circadian rhythms and their impact on quality of life, making them incorrect in this context.
Which nursing statement is an example of reflection?
- A. I think this feeling will pass.
- B. So you are saying that life has no meaning.
- C. I’m not sure I understand what you mean.
- D. You look sad.
Correct Answer: B
Rationale: The correct answer is B because it demonstrates reflective listening by paraphrasing and summarizing the patient's statement. This shows active listening and understanding of the patient's perspective. Choice A is about personal feelings, not reflecting the patient's emotions. Choice C is a statement of uncertainty, not reflective listening. Choice D is an observation, not reflection.
Which activity is most appropriate for a child with ADHD?
- A. Reading an adventure novel
- B. Monopoly
- C. Checkers
- D. Tennis
Correct Answer: D
Rationale: The most appropriate activity for a child with ADHD is D: Tennis. Tennis involves physical activity, which can help release excess energy and improve focus. It also requires quick thinking, coordination, and concentration, which can benefit children with ADHD. Reading an adventure novel (A) may be too sedentary, Monopoly (B) and Checkers (C) are more sedentary and may not provide enough physical activity or engagement to help manage ADHD symptoms effectively. Tennis provides a balance of physical activity and mental engagement, making it the most suitable choice.