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A male client with schizophrenia is demonstrating echolalia, which is becoming annoying to other clients on the unit. What intervention is best for the nurse to implement?
- A. Avoid recognizing the behavior.
- B. Isolate the client from other clients.
- C. Administer a PRN sedative.
- D. Escort the client to his room.
Correct Answer: D
Rationale: The correct answer is D: Escort the client to his room. Echolalia is a common symptom of schizophrenia, where the individual repeats words or phrases they hear. Escorting the client to his room provides a safe and appropriate environment for the client to engage in the behavior without bothering other clients. Avoiding recognition (choice A) may not address the behavior and could lead to escalation. Isolating the client (choice B) may be seen as punitive and could worsen the client's symptoms. Administering a sedative (choice C) should be a last resort and not the initial intervention for managing echolalia.
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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.
A client with an eating disorder tells the RN, "I’ve been eating only 400 calories per day and have been taking diuretics to lose weight.” What is the RN’s best response?
- A. “Your diet is very harmful and needs to be changed immediately.”
- B. “It’s important to monitor your calorie intake carefully.”
- C. “Have you noticed any physical effects from this low-calorie diet?”
- D. “The diuretics could be causing your body to lose essential nutrients.”
Correct Answer: D
Rationale: The correct response is D: “The diuretics could be causing your body to lose essential nutrients.” This response addresses both the client’s low-calorie diet and the use of diuretics, highlighting the potential harm caused by the diuretics in depleting essential nutrients from the body. By focusing on the specific issue of nutrient loss, the nurse can educate the client on the dangers of using diuretics for weight loss and encourage seeking professional help. Options A, B, and C do not address the potential harm of diuretics and may not adequately address the severity of the situation. Option C is more general and may not directly address the issue of nutrient loss.
While sitting in the day room of the mental health unit, a male adolescent avoids eye contact, looks at the floor, and talks softly when interacting verbally with the RN. The two trade places, and the RN demonstrates the client’s behaviors. What is the main goal of this therapeutic technique?
- A. Initiate a non-threatening conversation with the client.
- B. Dialog about the ineffectiveness of his interactions.
- C. Allow the client to identify the way he interacts.
- D. Discuss the client’s feelings when he responds.
Correct Answer: C
Rationale: The main goal of the therapeutic technique demonstrated by the RN is to allow the client to identify the way he interacts (Choice C). By mirroring the client's behaviors, the RN provides a reflection of the client's own actions, which can help the client become more self-aware of how he presents himself. This can lead to insight into his own behavior and communication style, facilitating personal growth and potential behavior change.
Choice A is incorrect because the main goal is not just to initiate conversation, but to promote self-awareness. Choice B is incorrect as the focus is not on discussing the ineffectiveness of interactions but rather on self-identification. Choice D is incorrect as the main focus is not on discussing the client's feelings but on allowing the client to recognize his own behavior patterns.
A client is admitted for bipolar disorder and alcohol withdrawal, depressive phase. Based on which assessment finding will the RN withhold the clonidine (Catapres) prescription?
- A. Blood pressure readings of 90/62 mmHg to 92/58 mmHg.
- B. Pulse rate of 68-78 BPM.
- C. Temperature of 99.5-99.7 F.
- D. Respiration rate of 24 breaths per minute.
Correct Answer: A
Rationale: The correct answer is A. Clonidine is a medication commonly prescribed for managing symptoms of alcohol withdrawal. Since it can lower blood pressure, it is crucial to monitor the client's blood pressure regularly. In this case, the client's blood pressure readings of 90/62 mmHg to 92/58 mmHg are low, indicating hypotension. Administering clonidine in this situation can further decrease blood pressure, potentially causing adverse effects like dizziness, light-headedness, or even fainting. Therefore, the RN should withhold the clonidine prescription to prevent exacerbating hypotension. Choices B, C, and D are within normal ranges and do not contraindicate the use of clonidine in this scenario.
A female client is brought to the emergency department after police officers found her disoriented, disorganized, and confused. The RN also determines that the client is homeless and is exhibiting suspiciousness. The client’s plan of care should include what priority problem?
- A. Acute confusion.
- B. Ineffective community coping
- C. Disturbed sensory perception.
- D. Self-care deficit.
Correct Answer: A
Rationale: The correct answer is A: Acute confusion. This is the priority problem because the client is disoriented, disorganized, and confused, indicating an altered mental status requiring immediate attention. Addressing acute confusion is crucial to ensure the client's safety and well-being.
Incorrect Choices:
B: Ineffective community coping is not the priority as the client's immediate cognitive impairment takes precedence.
C: Disturbed sensory perception does not align with the client's presentation of confusion and disorientation.
D: Self-care deficit may be a concern but is secondary to the acute confusion that needs urgent intervention.