Nokea
A male client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. What intervention is best for the RN to implement?
- A. Isolate the client from the other clients.
- B. Administer PRN sedative.
- C. Avoid recognizing the behavior.
- D. Escort the client to his room.
Correct Answer: C
Rationale: The correct answer is C: Avoid recognizing the behavior. Echolalia is the repetition of words or phrases spoken by others, common in schizophrenia. By not reinforcing or acknowledging the behavior, the client may eventually stop. Isolating the client (Choice A) may lead to feelings of rejection. Administering a sedative (Choice B) may not address the underlying behavior. Escorting the client to his room (Choice D) does not address the echolalia directly.
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A client with obsessive-compulsive disorder (OCD) repeatedly checks to see if the door is locked and asks for reassurance that it is locked. What is the most appropriate intervention by the RN to address this behavior?
- A. Set a specific limit on the number of times the client can check the door.
- B. Help the client find an alternative activity to perform.
- C. Provide consistent reassurance that the door is locked.
- D. Ignore the checking behavior and focus on other behaviors.
Correct Answer: A
Rationale: The correct answer is A: Set a specific limit on the number of times the client can check the door. This intervention helps establish boundaries and structure for the client, which can assist in reducing compulsive behaviors. By setting a specific limit, the client is encouraged to gradually decrease the checking behavior and learn to cope with the anxiety associated with uncertainty. This approach promotes independence and empowerment for the client.
Choice B is incorrect because finding an alternative activity does not directly address the obsessive checking behavior. Choice C is incorrect as providing consistent reassurance reinforces the compulsive behavior. Choice D is incorrect because ignoring the behavior does not actively address or help decrease the compulsive checking.
The nurse leading a group session of adolescent clients gives the members a handout about anger management. One of the male clients is fidgety, interrupts peers when they try to talk, and talks about his pets at home. What nursing action is best for the nurse to take?
- A. Give the client permission to leave and return in 10 minutes.
- B. Explore the client’s feelings about his pets and home life.
- C. Encourage his peers to help involve him in the activity.
- D. Redirect him by encouraging him to read from the handout.
Correct Answer: D
Rationale: The correct answer is D: Redirect him by encouraging him to read from the handout. This option addresses the client's behavior by redirecting his focus back to the group activity. By encouraging him to read from the handout, the nurse provides a constructive way for the client to engage with the material and participate in the session. This approach helps the client stay on track with the intended purpose of the group session, which is anger management.
Other choices are incorrect:
A: Giving the client permission to leave may reinforce disruptive behavior.
B: Exploring the client's feelings about his pets may not address the immediate issue of his behavior.
C: Involving peers may not effectively address the client's disruptive behavior.
Overall, option D is the most appropriate as it directly addresses the client's behavior and redirects him in a positive way.
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.
A patient being treated for insomnia is prescribed ramelteon (Rozerem). Which comorbid mental health condition would make this medication the hypnotic of choice for this particular patient?
- A. Obsessive-compulsive disorder
- B. Generalized anxiety disorder
- C. Persistent depressive disorder
- D. Substance use disorder
Correct Answer: D
Rationale: The correct answer is D: Substance use disorder. Ramelteon is a melatonin receptor agonist used to treat insomnia by regulating the sleep-wake cycle without the risk of dependence or abuse, making it ideal for patients with substance use disorder. People with substance use disorder often have disrupted sleep patterns, and ramelteon can help improve their sleep without the risk of worsening their substance use disorder.
A: Obsessive-compulsive disorder - Ramelteon does not specifically target symptoms of OCD.
B: Generalized anxiety disorder - While insomnia can be a symptom of GAD, other medications may be more suitable for addressing anxiety symptoms.
C: Persistent depressive disorder - Ramelteon may not directly address depressive symptoms, and other medications may be more effective for PDD.
Overall, the unique pharmacological profile of ramelteon makes it an appropriate choice for patients with substance use disorder who also have insomnia.
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.