A nurse in a community mental health clinic is caring for a group of clients. The nurse should encourage participation in cognitive behavioral family therapy in response to which of the following client statements?
- A. I want to learn how to change the way I react to problems within my family
- B. I want to understand why my past experiences are affecting my family relationships
- C. I want to improve my family’s understanding of each other’s boundaries
- D. I want each of my family members to be more aware of each other’s feelings
Correct Answer: A
Rationale: The correct answer is A because cognitive behavioral family therapy focuses on changing negative thought patterns and behaviors. By wanting to change the way they react to family problems, the client is demonstrating a readiness to engage in cognitive restructuring and behavioral change. Choice B is incorrect as it pertains more to individual therapy exploring past experiences. Choice C is incorrect as it focuses on improving understanding of boundaries, which is not the primary goal of cognitive behavioral family therapy. Choice D is incorrect because it emphasizes awareness of feelings rather than addressing reactive behaviors.
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A nurse is caring for a client who has schizophrenia and takes clozapine. Which of the following findings is a priority for the nurse to report to the provider?
- A. Nausea
- B. Random blood glucose 130 mg/dL
- C. Heart rate 104 per minute
- D. Sore throat
Correct Answer: D
Rationale: The correct answer is D: Sore throat. A priority finding to report with clozapine is agranulocytosis, which presents with symptoms like sore throat. This is crucial to detect early to prevent severe infection. A: Nausea is a common side effect of clozapine but not a priority over potential agranulocytosis. B: Random blood glucose of 130 mg/dL is slightly elevated but not an immediate concern. C: Heart rate of 104 per minute may be a side effect but is not as critical as agranulocytosis. Reporting the sore throat promptly can lead to timely intervention and prevent serious complications.
A nurse is providing discharge teaching to the parents of a child who has ADHD and a prescription for methylphenidate. Which of the following instructions should the nurse include?
- A. Administer the medication at bedtime
- B. Monitor the child’s weight frequently
- C. Give the medication with milk
- D. Discontinue the medication if insomnia occurs
Correct Answer: B
Rationale: The correct answer is B: Monitor the child’s weight frequently. This is important because methylphenidate, a stimulant used to treat ADHD, can potentially lead to appetite suppression and weight loss in children. Regular monitoring of the child's weight can help identify any significant changes and allow for appropriate interventions if needed.
Choice A is incorrect because administering the medication at bedtime can lead to insomnia due to its stimulant effects. Choice C is incorrect as there is no specific recommendation to give the medication with milk. Choice D is incorrect because insomnia is a common side effect of methylphenidate and does not necessarily warrant discontinuation of the medication unless severe or persistent.
A nurse in an inpatient mental health facility is assessing a client who has schizophrenia and is taking haloperidol. Which of the following clinical findings is the nurse’s priority?
- A. High fever
- B. Insomnia
- C. Urinary hesitancy
- D. Headache
Correct Answer: A
Rationale: The correct answer is A: High fever. The priority finding is high fever because it could indicate a potentially serious adverse reaction called neuroleptic malignant syndrome (NMS) associated with haloperidol use. NMS is a life-threatening condition characterized by fever, altered mental status, muscle rigidity, and autonomic dysfunction. Prompt recognition and treatment of NMS are crucial to prevent complications. Insomnia (B), urinary hesitancy (C), and headache (D) are common side effects of haloperidol but are not as urgent as high fever, which could signify a medical emergency.
A nurse is developing a behavioral contract with a client who has antisocial personality disorder. Which of the following client goals should the nurse include in the contract?
- A. Use projection during group therapy
- B. Increase self-esteem
- C. Use bargaining skills for behavioral consequences
- D. Decrease the number of verbal outbursts
Correct Answer: D
Rationale: The correct answer is D: Decrease the number of verbal outbursts. For a client with antisocial personality disorder, managing impulsivity and aggression is crucial. Decreasing verbal outbursts helps improve social interactions and relationships. Using projection (A) can exacerbate manipulative behavior. Increasing self-esteem (B) may not address the core issues of the disorder. Using bargaining skills (C) might reinforce manipulative tendencies rather than promoting genuine change in behavior.
A nurse is providing teaching for a school-age child and his parents regarding a new prescription for risperidone. Which of the following statements by the parent indicates an understanding of the teaching?
- A. I will provide a low sodium diet for my son
- B. I will make sure my son takes the last dose of the day by 4 PM
- C. I should expect my son to develop hand tremors
- D. I should contact my doctor if my son urinates excessively
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. Risperidone is known to cause sedation, so giving the last dose early can help minimize sleep disturbance.
2. Taking the last dose by 4 PM reduces the risk of insomnia or disrupted sleep patterns.
3. This statement shows the parent understands the importance of timing to optimize the medication's effects.
4. The other choices are incorrect because they do not directly relate to the appropriate use of risperidone.