Nokea
A nurse is caring for a client who has severe manifestations of schizophrenia and is medicated PRN for agitation with haloperidol. The nurse should assess the client for which of the following adverse effects?
- A. Dysrhythmias
- B. Cataracts
- C. Pancreatitis
- D. Bleeding
Correct Answer: A
Rationale: Haloperidol can cause QT prolongation, increasing the risk of dysrhythmias.
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A nurse is caring for a client who attacked one of her friends and is admitted to the psychiatric unit. Which of the following actions should the nurse take first?
- A. Establish a client relationship.
- B. Explain to the client that the behavior was unacceptable.
- C. Explore the truth of the client’s statements.
- D. Set behavioral limits for the client.
Correct Answer: D
Rationale: Setting behavioral limits helps establish expectations for the client’s conduct in the unit.
A nurse is assessing a parent who lost a 12-year-old child in a car crash 2 years ago. Which of the following findings indicates the client is exhibiting manifestations of prolonged grieving?
- A. Leaves the child's room exactly as it was before the loss
- B. Volunteers at a local children's hospital
- C. Talks about the child in the past tense
- D. Visits the child's grave every week after worship services
Correct Answer: A
Rationale: In prolonged grief, individuals may struggle to move forward and avoid changing their environment.
A nurse is caring for a client who has bipolar disorder and is running around the unit asking people to dance with her. Which of the following interventions should the nurse take?
- A. Turn on a dance video so the client can burn off excess energy.
- B. Offer the client a low-calorie snack in return for stopping the behavior.
- C. Walk the client outside and sit with her in the garden area.
- D. Observe the client closely for the development of aggressive behavior.
Correct Answer: C
Rationale: The correct answer is C: Walk the client outside and sit with her in the garden area. This intervention helps the client to redirect their energy in a positive and calming manner. Being outdoors can provide a change of environment, fresh air, and can help the client feel more grounded. It also offers a distraction from the impulsive behavior and promotes relaxation. Turning on a dance video (choice A) may further stimulate the client's behavior rather than calming them down. Offering a snack (choice B) may reinforce the behavior and is not addressing the underlying issue. Observing for aggressive behavior (choice D) is important but does not actively address the client's current behavior.
A nurse in the emergency department is implementing a plan of care for an older adult client who is experiencing delirium tremens. Which of the following actions should the nurse take first?
- A. Administer diazepam.
- B. Raise the side rails of the bed.
- C. Obtain a medical history.
- D. Start intravenous fluids.
Correct Answer: A
Rationale: The correct answer is A: Administer diazepam. Delirium tremens is associated with severe alcohol withdrawal and can be life-threatening. Diazepam is a benzodiazepine used to manage alcohol withdrawal symptoms by reducing agitation and preventing seizures. Administering diazepam first is crucial to stabilize the client's condition and prevent complications. Raising the side rails of the bed (B) can be important for safety but does not address the immediate medical need. Obtaining a medical history (C) is important for understanding the client's background but is not the priority in this acute situation. Starting intravenous fluids (D) may be necessary to address dehydration, but managing the withdrawal symptoms with diazepam takes precedence.
A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse identify as a negative symptom?
- A. Delusions
- B. Hallucinations
- C. Social withdrawal
- D. Agitation
- E. Flat affect
Correct Answer: C
Rationale: The correct answer is C: Social withdrawal. Negative symptoms in schizophrenia involve the absence or reduction of normal behaviors or functions. Social withdrawal is a common negative symptom, characterized by the client's lack of interest in social interactions. Delusions (A) and hallucinations (B) are positive symptoms, involving the presence of abnormal behaviors or perceptions. Agitation (D) is a symptom of increased motor activity, not a negative symptom. Flat affect (E) refers to a lack of emotional expression, which is also a negative symptom. In summary, social withdrawal aligns with the definition of negative symptoms in schizophrenia, making it the correct answer.