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A nurse is assessing a newly admitted client who has schizophrenia and takes thioridazine. Which of the following findings should the nurse document as an adverse effect of this medication?
- A. Anhedonia
- B. Waxy flexibility
- C. Contractions of the jaw
- D. Incongruent affect
Correct Answer: C
Rationale: The correct answer is C: Contractions of the jaw. Thioridazine is an antipsychotic medication known to cause extrapyramidal side effects such as dystonia, which can manifest as contractions of the jaw. Anhedonia (A) is the inability to experience pleasure, not a side effect of thioridazine. Waxy flexibility (B) is a symptom of catatonia, not a side effect of thioridazine. Incongruent affect (D) refers to a mismatch between expression and emotion, not a side effect of thioridazine.
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A nurse is assessing a client who has opioid intoxication. Which of the following findings should the nurse expect?
- A. Pinpoint pupils
- B. Hyperreflexia
- C. Increased respiratory rate
- D. Dilated pupils
Correct Answer: A
Rationale: The correct answer is A: Pinpoint pupils. Opioid intoxication causes miosis, resulting in constricted or pinpoint pupils. This occurs due to the suppression of the sympathetic nervous system. Hyperreflexia (B) is not typically associated with opioid intoxication; it is more common in conditions like spinal cord injury. Opioids depress the respiratory system, leading to decreased respiratory rate (C), not increased. Dilated pupils (D) are more indicative of stimulant intoxication, such as amphetamines.
A nurse in a mental health facility is caring for a client who has borderline personality disorder. Which of the following findings should the nurse expect?
- A. Persistent mood swings
- B. Hypersomnia
- C. Avoidance of eye contact
- D. Ritualistic behaviors
Correct Answer: A
Rationale: The correct answer is A: Persistent mood swings. Borderline personality disorder is characterized by unstable emotions, leading to frequent and intense mood swings. This is a hallmark feature of the disorder. Hypersomnia (choice B) is not typically associated with borderline personality disorder. Avoidance of eye contact (choice C) is more commonly seen in conditions like social anxiety disorder. Ritualistic behaviors (choice D) are more characteristic of obsessive-compulsive disorder, not borderline personality disorder. In summary, persistent mood swings are a key feature of borderline personality disorder, distinguishing it from the other options provided.
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 is planning care for a client who has experienced intimate partner abuse. The nurse should identify which of the following outcomes as the priority?
- A. The client joins a support group
- B. The client identifies techniques to reduce stress
- C. The client develops a safety plan
- D. The client identifies support systems
Correct Answer: C
Rationale: The correct answer is C: The client develops a safety plan. This is the priority outcome because it addresses the immediate safety of the client who is experiencing intimate partner abuse. A safety plan helps the client to identify strategies to protect themselves and seek help in times of danger. Joining a support group (A), identifying stress reduction techniques (B), and identifying support systems (D) are important steps in the client's overall recovery process but addressing safety concerns is crucial to prevent further harm. It is important to prioritize safety before addressing other aspects of the client's well-being.
A nurse is assessing a client who has generalized anxiety disorder. Which of the following findings should the nurse expect?
- A. Increased energy
- B. Restlessness
- C. Euphoric mood
- D. Depersonalization
Correct Answer: B
Rationale: The correct answer is B: Restlessness. In generalized anxiety disorder, individuals often experience restlessness due to persistent worry and fear. This can manifest as physical agitation and an inability to relax. Increased energy (A) is not typically associated with generalized anxiety disorder, as individuals may feel fatigued due to constant worrying. Euphoric mood (C) is more characteristic of conditions like bipolar disorder, not generalized anxiety disorder. Depersonalization (D) involves feeling detached from oneself and is more commonly associated with conditions like dissociative disorders, not generalized anxiety disorder.