Nokea
A nurse is caring for an adolescent client who begins to cry and states, 'Nobody loves me. I don't deserve to be here!' Which of the following responses should the nurse make?
- A. Why do you think nobody loves you?
- B. I am sure your parents love you
- C. Don't worry, things will get better.'
- D. Let's talk about what is upsetting you.'
Correct Answer: D
Rationale: The correct response is D: "Let's talk about what is upsetting you." This response is appropriate as it shows empathy, encourages communication, and allows the client to express their feelings. It opens up a dialogue for the nurse to understand the root cause of the client's distress and provide appropriate support.
Rationale:
1. Empathy: By acknowledging the client's emotions and offering to talk, the nurse shows empathy and support.
2. Communication: Encouraging the client to express their feelings promotes communication and helps the nurse understand the client's perspective.
3. Assessment: Talking about what is upsetting the client allows the nurse to assess the situation and provide appropriate interventions.
Summary of other choices:
A: Why do you think nobody loves you? - This response may come off as dismissive or invalidating the client's feelings.
B: I am sure your parents love you - This response assumes the client's parents love them without addressing the client's current distress.
C: Don't worry,
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After taking fluphenazine for several days, a client states to the nurse, 'For some reason I can't sit still restless all the time.' The nursing assessment of this client is likely to indicate which of the following?
- A. Tardive dyskinesia
- B. Pseudoparkinsonism
- C. Akathisia
- D. Acute dystonia
Correct Answer: C
Rationale: The correct answer is C: Akathisia. Akathisia is a common extrapyramidal side effect of antipsychotic medications like fluphenazine, causing an inner restlessness and inability to sit still. This is characterized by a compelling need to move and can be distressing for the client. Tardive dyskinesia (A) is a late-occurring side effect characterized by involuntary repetitive movements, not restlessness. Pseudoparkinsonism (B) presents with symptoms similar to Parkinson's disease such as tremors and rigidity. Acute dystonia (D) is a sudden onset of muscle spasms and abnormal postures, not restlessness.
The admitting nurse asks a client, 'Hi John, what would you like to talk about in group today?' The client replies, 'Hi john, what would you like to talk about in group today.' The nurse should recognize this response as an example of which of the following?
- A. Echolalia
- B. Word salad
- C. Flight of ideas
- D. Clanging
Correct Answer: A
Rationale: The correct answer is A: Echolalia. Echolalia is the repetition of words or phrases spoken by others. In this case, the client's response mirrors exactly what the nurse said, indicating a repetitive behavior. The other choices are incorrect because: B: Word salad is a jumble of unrelated words or phrases, which is not demonstrated in the client's response. C: Flight of ideas refers to a rapid, continuous flow of speech with abrupt changes in topic, which is not evident here. D: Clanging involves stringing together words based on sound, not meaning, which is not present in the client's response.
Client's behavior continues to escalate. A nurse is caring for a client in an inpatient psychiatry unit, Drag words from the choices below to fill in each blank in the following sentence ,Which of the following actions should the nurse take first? The nurse should ___ followed by ___.
- A. Place the client in restraints
- B. Grab the client's hand
- C. Offer the client a physical outlet
- D. Offer the client medication
Correct Answer: C,D
Rationale: Action to Take: Offer the client a physical outlet, Offer the client medication; Potential Condition: Escalating behavior; Parameter to Monitor: Client's behavior, Client's response to offered outlets.
Rationale: When a client's behavior continues to escalate in an inpatient psychiatry unit, the nurse's first action should be to offer the client a physical outlet as a non-restrictive and non-confrontational approach to de-escalate the situation. This allows the client to release built-up tension and energy in a safe manner. Additionally, offering medication can help address any underlying anxiety or agitation contributing to the escalation. By monitoring the client's behavior and response to the offered outlets, the nurse can assess the effectiveness of the interventions and make further adjustments as needed. Placing the client in restraints should be avoided as it can escalate the situation further, and grabbing the client's hand may be perceived as confrontational or threatening, potentially worsening the behavior.
A client is experiencing a severe psychotic episode, and is newly admitted to the psychiatric unit. Which action by the nurse should be priority?
- A. Ensure the client does not injure themselves
- B. Ensure the client has information regarding their diagnosis
- C. Call the family and discuss a family therapy session
- D. Call the doctor to request loxapine
Correct Answer: A
Rationale: The correct answer is A: Ensure the client does not injure themselves. Priority in psychiatric emergencies is to ensure safety. During a severe psychotic episode, the client may be at risk of harming themselves or others. By ensuring the client's safety first, the nurse can prevent potential harm. B: Providing information on diagnosis is important but not a priority during a crisis. C: Family therapy is beneficial but not immediate priority. D: Requesting medication is important but ensuring safety takes precedence.
A patient states to the nurse, 'I have no idea what typical antipsychotics but now I've been asked to take them.' What symptoms should the nurse be prepared to discuss with the client?
- A. Delirium and anxiety
- B. Dry mouth and blurry vision
- C. Dysrthythmia and headache
- D. Diarrhea and flatus
Correct Answer: B
Rationale: The correct answer is B: Dry mouth and blurry vision. Typical antipsychotics are known to cause anticholinergic side effects like dry mouth and blurry vision. Dry mouth is due to the medication's ability to block acetylcholine, leading to reduced salivary gland secretion. Blurry vision results from antipsychotics' effects on the eye's muscarinic receptors. Delirium and anxiety (choice A) are not typical side effects of typical antipsychotics. Dysrhythmia and headache (choice C) are also not commonly associated with this medication class. Diarrhea and flatus (choice D) are more commonly seen with gastrointestinal medications rather than antipsychotics.