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A nurse is creating a plan of care for a client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan?
- A. Weigh the client twice per day
- B. Prepare the client for electroconvulsive therapy
- C. Set a weight gain goal of 2.2kg (5lbs) per week
- D. Encourage the client to participate in family therapy
Correct Answer: C
Rationale: The correct answer is C: Set a weight gain goal of 2.2kg (5lbs) per week. This intervention is appropriate for a client with anorexia nervosa to promote healthy weight restoration. Rapid weight gain can be harmful, so setting a realistic goal helps prevent complications. Weighing the client twice per day (A) can exacerbate anxiety and reinforce obsessive behaviors. Electroconvulsive therapy (B) is not indicated for anorexia nervosa. Encouraging family therapy (D) may be beneficial, but the priority is weight restoration.
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A nurse is assessing a client who is experiencing alcohol withdrawal. For which of the following findings should the nurse anticipate administration of lorazepam?
- A. Bradycardia
- B. Stupor
- C. Afebrile
- D. Hypertension
Correct Answer: D
Rationale: The correct answer is D: Hypertension. Lorazepam is a benzodiazepine commonly used to manage alcohol withdrawal symptoms, including hypertension. Alcohol withdrawal often leads to increased sympathetic nervous system activity, causing elevated blood pressure. Lorazepam helps to reduce this symptom by promoting relaxation and reducing anxiety. Bradycardia (A), stupor (B), and afebrile (C) are not indications for lorazepam administration in alcohol withdrawal. Bradycardia and stupor may require further evaluation for potential complications, while afebrile state does not directly warrant lorazepam use.
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.
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
Correct Answer: C
Rationale: The correct answer is C: Social withdrawal. Negative symptoms in schizophrenia involve a decrease or absence of normal functions. Social withdrawal is a classic negative symptom, as it reflects a reduction in social interactions and interest. Delusions (A) and hallucinations (B) are positive symptoms, characterized by the presence of abnormal behaviors. Agitation (D) is associated with agitation and restlessness, not with negative symptoms. In summary, social withdrawal is the correct answer because it aligns with the definition of negative symptoms in schizophrenia.
A nurse is planning care for a client with acute delirium. Which of the following instructions should the nurse include in the plan?
- A. Reinforce the clients orientation with the calendar
- B. Refute the clients perception of visual hallucinations
- C. Teach the client assertive techniques
- D. Assign the client to a different caregiver each shift
Correct Answer: A
Rationale: The correct answer is A: Reinforce the client's orientation with the calendar. This is because in acute delirium, the client may experience confusion and disorientation. Using a calendar can help provide structure and aid in orientation. Choice B is incorrect as refuting hallucinations may worsen the client's agitation. Choice C is incorrect as assertive techniques are not typically used in managing acute delirium. Choice D is incorrect as consistency in caregivers is important for continuity of care in delirium management.
A nurse in a mental health facility is assessing a client who has schizophrenia. The nurse should document which of the following as a positive symptom?
- A. Social withdrawal
- B. Flat affect
- C. Delusions
- D. Lack of motivation
Correct Answer: C
Rationale: The correct answer is C: Delusions. Positive symptoms are behaviors or experiences that are added to a person's personality, such as hallucinations or delusions. Delusions are false beliefs that are not based on reality. In the context of schizophrenia, delusions are considered positive symptoms because they represent an addition to a person's usual behavior or mental state. Social withdrawal (A), flat affect (B), and lack of motivation (D) are considered negative symptoms of schizophrenia, as they involve a decrease or absence of normal behaviors or emotions. Therefore, the nurse should document delusions as a positive symptom in the assessment of the client with schizophrenia.