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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. 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. Administer the prescribed anticholinergic benztropine for dystonia
- B. Offer the client a prescribed physical therapy hot pack for muscle spasms
- C. Direct the client to occupational therapy to distract him from somatic complaints
- D. Medicate the client with the prescribed antipsychotic thioridazine
Correct Answer: A
Rationale: The client's laterally contracted position and perception of contortion suggest acute dystonia, a side effect of risperidone. Benztropine, an anticholinergic, alleviates dystonia. Hot packs, occupational therapy, or thioridazine do not address this acute reaction.
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A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?
- A. Ask the client to describe and identify the source of the feelings
- B. Provide education about ways to cope with anxiety
- C. Assist the client with relaxation techniques in the group
- D. Escort the client from the group to reduce stimuli
Correct Answer: C
Rationale: Assisting the client with relaxation techniques in the group is the best intervention as it provides immediate support and can help alleviate the client's anxiety in the moment. Exploring the source of anxiety may not be suitable during a group session where immediate relief is needed. Education on coping mechanisms is valuable but does not address immediate needs. Escorting the client out may be considered if anxiety becomes overwhelming, but it is secondary to attempting in-group relaxation.
The nurse is performing the admission assessment for a client with schizophrenia in an acute care inpatient facility. The nurse should identify which observed behavior is characteristic of schizophrenia?
- A. Responds with illogical answers to questions
- B. Admits to frequently thinking about committing suicide
- C. Describes times of depression followed by feelings of euphoria
- D. Exhibits compulsive, ritualistic behaviors
Correct Answer: A
Rationale: Responding with illogical answers indicates disorganized thinking, a hallmark of schizophrenia during psychosis. Suicide thoughts are not specific to schizophrenia. Depression and euphoria suggest bipolar disorder. Compulsive behaviors are more typical of OCD.
A client who has agoraphobia is beginning desensitization with the therapist, and the nurse is reinforcing the process. Which intervention has the highest priority for this client's plan of care?
- A. Establish trust by providing a calm, safe environment
- B. Encourage deep breathing when anxiety escalates in a crowd
- C. Progressively expose the client to larger crowds
- D. Encourage substitution of positive thoughts for negative ones
Correct Answer: A
Rationale: Establishing trust through a calm, safe environment is foundational for effective desensitization in agoraphobia, supporting the client's sense of security. Deep breathing and positive thoughts are secondary. Progressive exposure comes after trust is established.
A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?
- A. Ineffective sexual patterns
- B. Disturbed sensory perception
- C. Compromised family coping
- D. Impaired environmental interpretation
Correct Answer: B
Rationale: The client's delusions (e.g., being married to a movie star, brother's intentions) indicate disturbed sensory perception, suggestive of psychosis, which is the priority. Ineffective sexual patterns are not directly indicated. Family coping may be secondary. Impaired environmental interpretation is too broad.
The nurse is admitting a male client who takes lithium carbonate twice a day. Which information should the nurse report to the healthcare provider immediately?
- A. Nausea and vomiting
- B. Short-term memory loss
- C. Five-pound (2.3 kg) weight gain
- D. Depressed affect
Correct Answer: A
Rationale: Nausea and vomiting could indicate lithium toxicity, requiring immediate attention to prevent serious complications. Memory loss and weight gain are common side effects but less urgent. Depressed affect may relate to the underlying condition but is not immediately life-threatening.