Nokea
A nurse is caring for a client who was admitted with acute psychosis and is being treated with haloperidol. The nurse should suspect that the client may be experiencing tardive dyskinesia when the client exhibits which of the following? (Select all that apply.)
- A. Urinary retention and constipation
- B. Tongue thrusting and lip smacking
- C. Fine hand tremors and pill rolling
- D. Facial grimacing and eye blinking
- E. Involuntary pelvic rocking and hip thrusting movements
Correct Answer: B, D, E
Rationale: Tardive dyskinesia involves involuntary repetitive movements such as lip smacking, facial grimacing, and pelvic rocking.
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A nurse on an acute mental health unit is caring for a client who has major depressive disorder. Which of the following interventions is the nurse’s priority?
- A. Monitor for risk of self-harm.
- B. Administer prescribed antidepressants.
- C. Encourage adequate fluid intake.
- D. Assist with activities of daily living.
Correct Answer: A
Rationale: The correct answer is A: Monitor for risk of self-harm. This is the priority because individuals with major depressive disorder are at an increased risk for suicide. The nurse must ensure the client's safety by closely monitoring for any signs of self-harm or suicidal ideation. Administering antidepressants (B) may be important for long-term management but ensuring immediate safety takes precedence. Encouraging fluid intake (C) and assisting with activities of daily living (D) are important aspects of care but do not address the immediate risk of self-harm.
A nurse is teaching a community education course about the physical complications related to substance use disorder. Which of the following findings should the nurse include in the discussion as a health risk of heroin use?
- A. Acute pancreatitis
- B. Slowed breathing
- C. Nasal septum perforation
- D. Permanent short-term memory loss
Correct Answer: B
Rationale: Heroin depresses the central nervous system, leading to respiratory depression.
A nurse is assessing a client who is to undergo a left lobectomy to treat lung cancer. The client tells the nurse that she is scared and wishes she had never smoked. Which of the following responses should the nurse make?
- A. "It's okay to feel scared. Let's talk about what you are afraid of."
- B. "Don't worry. The important thing is you have now quit smoking."
- C. "I understand your fears. I was a smoker also."
- D. "Your doctor is a great surgeon. You will be fine."
Correct Answer: A
Rationale: The correct answer is A: "It's okay to feel scared. Let's talk about what you are afraid of." This response shows empathy and acknowledges the client's feelings, which is an essential aspect of therapeutic communication. By inviting the client to talk about her fears, the nurse creates a safe space for the client to express her emotions and concerns. This can help alleviate anxiety and build trust between the client and the nurse.
Choices B, C, and D are incorrect because they do not directly address the client's emotional state or offer support. B focuses on smoking cessation, which may not be the immediate concern for the client undergoing surgery. C shifts the focus to the nurse's personal experience, which may detract from the client's needs. D dismisses the client's fears and offers reassurance without addressing the underlying emotions.
A nurse is caring for a client who has delusional behavior and states, "I can't go to group therapy today. I am expecting a high-level official to visit me." The nurse responds, "I understand, but it is time for group therapy, and we expect everyone to attend. Let's walk over together.” For which of the following reasons is the nurse's response considered therapeutic?
- A. It clearly articulates what is expected of the client.
- B. It demonstrates empathy towards the delusion.
- C. It sets limits on the client's manipulative behavior.
- D. It uses reflection when talking with the client.
Correct Answer: A
Rationale: The correct answer is A because the nurse's response clearly articulates what is expected of the client, which helps maintain structure and promote accountability. By stating the expectation for the client to attend group therapy, the nurse is establishing boundaries and reinforcing the therapeutic environment. This approach helps the client understand the importance of participating in treatment activities.
Choice B is incorrect because empathy towards the delusion may validate the client's false beliefs, which is not therapeutic in this context. Choice C is incorrect as the response is not primarily aimed at setting limits on manipulative behavior but rather at promoting participation in therapy. Choice D is incorrect as the response does not involve reflection but rather straightforward communication of expectations.
A nurse is caring for a client who has late-stage Alzheimer's disease and is hospitalized for treatment of pneumonia. During the night shift, the client is found climbing into the bed of another client who becomes upset and frightened. Which of the following actions should the nurse take?
- A. Assist the client to the correct room.
- B. Place the client in restraints.
- C. Reorient the client to time and place.
- D. Move the client to a room at the end of the hall.
Correct Answer: A
Rationale: Redirecting the client to their correct room is the least restrictive intervention while ensuring safety.