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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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Gilbert, age 19, is described by his parents as a 'moody child' with an onset of odd behavior about at age 14, which caused Gilbert to suffer academically and socially. Gilbert has lost the ability to complete household chores, is reluctant to leave the house, and is obsessed with the locks on the windows and doors. Due to Gilbert’s early and slow onset of what is now recognized as schizophrenia, his prognosis is considered:
- A. Favorable with medication
- B. In the relapse stage
- C. Improvable with psychosocial interventions
- D. To have a less positive outcome
Correct Answer: D
Rationale: The correct answer is D: To have a less positive outcome. Gilbert's symptoms of odd behavior, academic decline, social withdrawal, inability to perform household chores, and obsession with locks are indicative of schizophrenia, a severe and chronic mental disorder. Onset at a young age and slow progression are associated with a poorer prognosis. Medication can help manage symptoms but may not completely alleviate them. Psychosocial interventions may offer some support but are unlikely to significantly alter the course of the illness. The relapse stage implies some improvement followed by worsening, which is not described in Gilbert's case. Therefore, option D is the most appropriate as it reflects the challenging nature of schizophrenia in young individuals like Gilbert.
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.
What assessment question should the nurse ask when attempting to determine a teenager’s mental health resilience? Select all that apply.
- A. How did you cope when your father deployed with the Army for a year in Iraq?
- B. Who did you go to for advice while your father was away for a year in Iraq?
- C. How do you feel about talking to a mental health counselor?
- D. Where do you see yourself in 10 years?
Correct Answer: C
Rationale: The correct answer is C: How do you feel about talking to a mental health counselor? This question is crucial in assessing a teenager's mental health resilience as it directly addresses their willingness to seek professional help and their attitude towards mental health support. By asking this question, the nurse can gauge the teenager's openness to counseling, which is an important aspect of resilience-building.
Choices A, B, and D are incorrect because they do not directly assess the teenager's mental health resilience. Questioning coping strategies (A), seeking advice (B), or future aspirations (D) may provide valuable information, but they do not specifically address the individual's attitude towards seeking professional mental health support, which is essential for determining resilience in this context.
When developing a plan of care for a client admitted to the psychiatric unit following aspiration of a caustic material related to a suicide attempt, which nursing problem has the highest priority?
- A. Impaired comfort.
- B. Risk for injury.
- C. Ineffective breathing pattern.
- D. Ineffective coping.
Correct Answer: C
Rationale: The correct answer is C: Ineffective breathing pattern. This is the highest priority because aspiration of a caustic material can lead to respiratory distress or compromise. Ensuring the client has a patent airway and adequate breathing is crucial for immediate stabilization and preventing further complications. Impaired comfort (choice A) may be a concern but is secondary to ensuring the client can breathe. Risk for injury (choice B) is important but not as immediate as addressing breathing. Ineffective coping (choice D) is important for long-term recovery but addressing the client's breathing takes precedence in this acute situation.
Which therapeutic communication statement might a psychiatric-mental health registered nurse use when a patient’s nursing diagnosis is altered thought processes?
- A. I know you say you hear voices, but I cannot hear them.
- B. Stop listening to the voices, they are NOT real.
- C. You say you hear voices, what are they telling you?
- D. Please tell the voices to leave you alone for now.
Correct Answer: C
Rationale: The correct answer is C because it demonstrates active listening and encourages the patient to express their experiences. By asking "You say you hear voices, what are they telling you?" the nurse shows empathy, validation, and a non-judgmental attitude towards the patient's altered thought processes. This statement helps the patient feel heard and understood, fostering a therapeutic nurse-patient relationship.
Choice A is incorrect because it dismisses the patient's experience and does not acknowledge their reality. Choice B is incorrect as it commands the patient to stop listening to the voices without addressing the underlying issues. Choice D is incorrect because it suggests the patient has control over the voices, which may not be the case.