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A nurse in a psychiatric unit is caring for several clients. Which of the following clients should the nurse recommend for group therapy?
- A. A client who has been taking amitriptyline for 3 months for depression.
- B. A client exhibiting psychotic behavior.
- C. A client admitted 12 hours ago for acute mania.
- D. A client who is experiencing alcohol intoxication.
Correct Answer: A
Rationale: Clients who have stabilized with medication are appropriate for group therapy.
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A nurse asks a client who is suicidal to make a safety contract, but the client declines. Which of the following actions should the nurse identify as the priority?
- A. Lock the doors to the unit and secure windows so they cannot be opened.
- B. Provide the client with plastic eating utensils for meals.
- C. Remove any objects from the client's environment that could be used for self-harm.
- D. Assign a staff member to stay with the client at all times.
Correct Answer: D
Rationale: A client who refuses a safety contract is at high risk, requiring constant supervision to ensure safety.
A nurse is caring for a client who was admitted to the facility in critical condition following a cerebrovascular accident. The client's son says to the nurse, "I wish I could stay, but I need to go home to see how my children are doing. I really hate to leave." Which of the following responses should the nurse make?
- A. "Perhaps you could call your children to see how they are doing."
- B. "Don't worry. I'll take good care of your parent while you are gone."
- C. "You are feeling drawn in two separate directions."
- D. "There's nothing you can do here. You should go home to your children."
Correct Answer: C
Rationale: Rationale for Correct Answer C: The nurse should acknowledge the son's feelings of being torn between staying with his parent and going home to his children. This response demonstrates empathy and understanding of the son's emotional struggle, validating his concerns. By acknowledging his conflicting emotions, the nurse can help the son process his feelings and make a decision that aligns with his needs and responsibilities.
Summary of Incorrect Choices:
A: This response does not address the son's emotional conflict and does not offer support or validation.
B: This response focuses on the nurse's care for the parent, disregarding the son's emotional needs.
D: This response dismisses the son's concerns and suggests leaving without considering his emotional state or responsibilities.
A nurse in an emergency department is assessing a client who has been taking haloperidol for 3 months. The client has a temperature of 39.5° C (103.4° F), blood pressure of 150/110 mm Hg, and muscle rigidity. Which of the following complications should the nurse suspect?
- A. Agranulocytosis
- B. Akathisia
- C. Tardive dyskinesia
- D. Neuroleptic malignant syndrome
Correct Answer: D
Rationale: The correct answer is D: Neuroleptic malignant syndrome (NMS). The client's symptoms of high fever, hypertension, and muscle rigidity are classic signs of NMS, a rare but life-threatening adverse effect of antipsychotic medications like haloperidol. NMS is a medical emergency that can lead to severe complications such as rhabdomyolysis, renal failure, and even death if not promptly recognized and treated. Agranulocytosis (A) is a potential side effect of some antipsychotic medications but typically presents with symptoms like fever and sore throat due to low white blood cell count. Akathisia (B) is a movement disorder characterized by restlessness and a compelling need to move, which is not consistent with the client's symptoms. Tardive dyskinesia (C) is a late-onset movement disorder associated with long-term antipsychotic use and typically presents with involuntary movements of the face and extremities, not fever
A nurse is performing an admission assessment for a client who has schizophrenia. Which of the following findings should the nurse identify as a negative symptom?
- A. Affective flattening.
- B. Bizarre behavior.
- C. Illogicality.
- D. Somatic delusions.
Correct Answer: A
Rationale: The correct answer is A: Affective flattening. Negative symptoms in schizophrenia refer to deficits in normal emotional responses or behaviors. Affective flattening specifically involves a reduction in the expression of emotions, such as reduced facial expressions and tone of voice. This is a core negative symptom in schizophrenia. Bizarre behavior (choice B) is associated with positive symptoms, such as hallucinations and delusions. Illogicality (choice C) is a cognitive symptom related to disorganized thinking. Somatic delusions (choice D) are also positive symptoms involving false beliefs about the body. By process of elimination, Affective flattening is the correct answer.
A nurse is caring for a client who has dementia. When performing a Mental Status Examination (MSE), the nurse should include which of the following data? (Select all that apply.)
- A. Ability to perform calculations
- B. Coping skills
- C. Recall ability
- D. Long-term memory
- E. Level of orientation
Correct Answer: A, C, D, E
Rationale: The correct answers are A, C, D, and E. In a Mental Status Examination for a client with dementia, assessing the ability to perform calculations (A) is important to evaluate cognitive function. Recall ability (C) is crucial as memory impairment is a common feature of dementia. Long-term memory (D) is essential to assess for signs of cognitive decline. The level of orientation (E) is vital to determine the client's awareness of time, place, and person, which can be impaired in dementia. Coping skills (B) are important but not typically assessed in an MSE for dementia. The other choices (F, G) do not directly relate to the cognitive impairment typically seen in dementia.