Nokea
A nurse in an outpatient mental health clinic is assessing an adolescent client. The nurse should expect the adolescent to be in which of the following of Erikson's stages of psychosocial development?
- A. Generativity vs self-absorption
- B. Trust vs mistrust
- C. Intimacy vs isolation
- D. Identity vs role confusion
Correct Answer: D
Rationale: The correct answer is D: Identity vs role confusion. Adolescents typically fall into this stage, characterized by exploring and establishing their sense of self and identity. They may question their roles and values, seeking to understand who they are. Choice A (Generativity vs self-absorption) is more relevant to middle adulthood. Choice B (Trust vs mistrust) is for infancy. Choice C (Intimacy vs isolation) is for young adulthood.
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A nurse is assessing a client who has histrionic personality disorder. Which of the following manifestations should the nurse expect?
- A. Suspicious of others
- B. Callousness
- C. Self-centered behavior
- D. Violates others' rights
Correct Answer: C
Rationale: The correct answer is C: Self-centered behavior. Histrionic personality disorder is characterized by attention-seeking behavior, excessive emotions, and a need for approval. Individuals with this disorder often exhibit self-centered behavior to gain attention and validation from others. Choice A is incorrect as suspicion of others is more indicative of paranoid personality disorder. Choice B, callousness, is not a typical feature of histrionic personality disorder, but rather more aligned with antisocial personality disorder. Choice D, violating others' rights, is more characteristic of individuals with antisocial personality disorder as well.
A client with schizophrenia is prescribed risperidone. Which of the following should the nurse monitor for as an adverse effect of this medication?
- A. Increased blood pressure
- B. Weight gain
- C. Excessive salivation
- D. Bradycardia
Correct Answer: B
Rationale: The correct answer is B: Weight gain. Risperidone, an atypical antipsychotic, is known to cause metabolic side effects such as weight gain. This occurs due to its effects on increasing appetite and altering metabolism. Monitoring weight regularly is crucial to detect and manage this adverse effect to prevent complications like diabetes and cardiovascular issues. Increased blood pressure (A) is not a common adverse effect of risperidone. Excessive salivation (C) is more commonly associated with medications like clozapine. Bradycardia (D) is not a typical side effect of risperidone.
A nurse is caring for a client who has a history of opioid use disorder. Which medication should the nurse anticipate administering to prevent withdrawal symptoms?
- A. Methadone
- B. Disulfiram
- C. Naloxone
- D. Bupropion
Correct Answer: A
Rationale: The correct answer is A: Methadone. Methadone is a long-acting opioid agonist that helps prevent withdrawal symptoms in individuals with opioid use disorder by stabilizing opioid receptors. This allows for gradual withdrawal and reduces cravings. Disulfiram (B) is used for alcohol use disorder. Naloxone (C) is an opioid antagonist used for opioid overdose reversal. Bupropion (D) is used for smoking cessation and depression, not opioid withdrawal.
A nurse is teaching a client who has generalized anxiety disorder about buspirone. Which statement indicates the client understands the teaching?
- A. I should take this medication as needed for acute anxiety.
- B. I may experience sedation and drowsiness with this medication.
- C. I should avoid grapefruit juice while taking this medication.
- D. This medication has a risk for dependence.
Correct Answer: C
Rationale: The correct answer is C because grapefruit juice can interact with buspirone, leading to an increased risk of side effects. Taking the medication with grapefruit juice can affect its absorption and metabolism, potentially altering its effectiveness. Choice A is incorrect because buspirone is typically taken regularly, not as needed. Choice B is incorrect because buspirone is not known for causing significant sedation or drowsiness. Choice D is incorrect because buspirone is not associated with a risk for dependence.
A nurse in an acute care mental health facility is placing a client in seclusion and restraints. Which of the following actions should the nurse plan to take?
- A. Ensure that the prescription for restraints be renewed every 6 hr.
- B. Document the client's behavior every 15 min.
- C. Request a provider to evaluate the client in person every 36 hr.
- D. Plan to monitor the client every 30 min while restrained.
Correct Answer: B
Rationale: The correct answer is B: Document the client's behavior every 15 min. This action is important to ensure the client's safety and monitor their response to seclusion and restraints. Documenting behavior every 15 minutes allows the nurse to track changes, identify any signs of distress, and ensure the client's well-being. It also helps in providing a detailed record of the client's condition for further evaluation and decision-making.
The other choices are incorrect because:
A: Ensuring the prescription for restraints be renewed every 6 hr is not necessary for immediate monitoring and safety.
C: Requesting a provider to evaluate the client in person every 36 hr is not frequent enough for close monitoring and intervention.
D: Planning to monitor the client every 30 min while restrained is not as frequent as every 15 minutes, which may miss important changes in behavior or condition.