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A nurse is assessing a child in the emergency department. Which of the following findings places the child at the greatest risk for physical abuse?
- A. The child is 10 years old
- B. The child is home-schooled
- C. The child has no siblings
- D. The child has cystic fibrosis
Correct Answer: A
Rationale: The correct answer is A: The child is 10 years old. Children between 8-12 years old are at higher risk for physical abuse due to increased independence and potential conflicts with caregivers. Being 10 years old puts the child at a critical age for abuse. Choice B (home-schooled) does not directly correlate with an increased risk of abuse. Choice C (no siblings) does not indicate abuse risk. Choice D (cystic fibrosis) is a medical condition and does not specifically increase the risk of physical abuse.
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A nurse in a psychiatric unit is planning care for a client who has paranoid personality disorder. Which of the following interventions should the nurse include?
- A. Encourage group therapy participation
- B. Avoid challenging the client’s paranoid beliefs
- C. Maintain eye contact during conversations
- D. Use humor to reduce the client’s anxiety
Correct Answer: B
Rationale: The correct answer is B: Avoid challenging the client’s paranoid beliefs. This is essential because challenging the client's beliefs can lead to increased defensiveness and mistrust. Instead, the nurse should validate the client's feelings without reinforcing the delusions. Encouraging group therapy (choice A) may exacerbate paranoia by increasing feelings of being scrutinized. Maintaining eye contact (choice C) may be perceived as threatening. Using humor (choice D) could be misinterpreted and lead to further distrust.
A nurse is teaching about benztropine to a client who has schizophrenia. Which of the following statements should the nurse include in the teaching?
- A. This medication is given to help with extrapyramidal side effects
- B. This medication is given to help with your depression
- C. Benztropine helps alleviate your hallucinations
- D. Benztropine is used to counteract your tachycardia
Correct Answer: A
Rationale: Correct Answer: A: This medication is given to help with extrapyramidal side effects.
Rationale:
1. Benztropine is an anticholinergic medication commonly used to manage extrapyramidal side effects (EPS) caused by antipsychotic medications.
2. EPS include symptoms like tremors, muscle stiffness, and restlessness, which can occur with antipsychotic use.
3. By blocking certain neurotransmitters in the brain, benztropine helps alleviate these side effects.
4. Other choices are incorrect:
- B: Benztropine does not treat depression, as it is not an antidepressant.
- C: Benztropine does not directly address hallucinations, which are typically managed with antipsychotic medications.
- D: Benztropine does not specifically target tachycardia, which may be a side effect of other medications but not the primary indication for benztropine use.
A nurse is providing teaching to a client who has depression and a new prescription for amitriptyline. Which of the following statements should the nurse include?
- A. Take this medication at bedtime
- B. Expect to see improvement within 24 hours
- C. Avoid eating foods high in tyramine
- D. Stop the medication once you feel better
Correct Answer: A
Rationale: The correct answer is A: Take this medication at bedtime. Amitriptyline is a tricyclic antidepressant that can cause drowsiness and sedation, so taking it at bedtime can help minimize these side effects. It also helps improve adherence to the medication regimen. Choice B is incorrect because it takes several weeks to see the full effects of amitriptyline, not within 24 hours. Choice C is incorrect because tyramine restriction is typically associated with MAOIs, not tricyclic antidepressants like amitriptyline. Choice D is incorrect because abruptly stopping amitriptyline can lead to withdrawal symptoms and a potential relapse of depression.
A nurse is assessing a client who is withdrawing from heroin. Which of the following manifestations should the nurse expect?
- A. Slurred speech
- B. Hypotension
- C. Bradycardia
- D. Hyperthermia
Correct Answer: D
Rationale: The correct answer is D: Hyperthermia. Heroin withdrawal can lead to hyperthermia due to increased metabolic activity, dehydration, and dysregulation of the body's temperature control mechanisms. Slurred speech (A) is not a typical manifestation of heroin withdrawal. Hypotension (B) and bradycardia (C) are more commonly associated with opioid overdose rather than withdrawal. In withdrawal, the client may actually experience hypertension and tachycardia due to increased sympathetic activity.
A nurse is providing teaching to a client who has obsessive-compulsive disorder and engages in excessive handwashing. Which of the following instructions should the nurse include?
- A. Encourage the client to stop washing hands
- B. Allow additional time for rituals
- C. Limit ritual behaviors immediately
- D. Ignore the compulsions
Correct Answer: B
Rationale: The correct answer is B: Allow additional time for rituals. This is because abruptly stopping the handwashing rituals can lead to increased anxiety and distress for the client. Allowing additional time for rituals can help the client feel more in control and gradually work towards reducing the behavior. Encouraging the client to stop washing hands (A) abruptly can be counterproductive. Limiting ritual behaviors immediately (C) can also increase anxiety. Ignoring the compulsions (D) may worsen the condition.