A nurse is performing an admission assessment. The patient complains that it has been taking larger and larger amounts of medication to get the desired effect. Based on this information, the nurse interprets this as suggesting which of the following?
- A. Desensitization
- B. Tolerance
- C. Therapeutic index
- D. Toxicity
Correct Answer: B
Rationale: Tolerance occurs when a patient requires increasing doses of a medication to achieve the same effect, as described. Desensitization is a broader term, therapeutic index measures safety margins, and toxicity indicates harmful effects, not increased dose requirements.
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A patient has been prescribed clozapine for treatment of schizophrenia. Which of the following would the nurse include in the teaching plan for this patient and family?
- A. You may experience hypertension while taking this medication.
- B. One of the side effects of this medication is breast engorgement.
- C. People taking this medication often experience dermatitis.
- D. You may experience noticeable weight gain while taking this medication.
Correct Answer: D
Rationale: Clozapine is associated with significant weight gain, a common side effect that should be included in patient education. Hypertension, breast engorgement, and dermatitis are not typical side effects of clozapine.
A nurse is preparing a patient for electroconvulsive therapy. Which of the following would the nurse include in the patient?s plan of care? Select all that apply.
- A. Ensuring that there is a signed informed consent on the patient?s chart
- B. Telling the patient he can have fluids but no food before the procedure
- C. Alerting the patient to the possibility of confusion after the treatment
- D. Informing the patient that he can leave his dentures in place for the treatment
- E. Ensuring that the patient is closely supervised for at least the first 12 hours afterward
Correct Answer: A,C,E
Rationale: ECT requires informed consent (A), warning about post-procedure confusion (C), and close supervision afterward (E) due to risks like disorientation. Patients must be NPO (no food or fluids) before ECT, and dentures must be removed to prevent airway obstruction, making B and D incorrect.
A hospitalized patient who has been taking an antipsychotic medication for 2 weeks begins pacing and walking throughout the unit. He tells the nurse that he cannot sit still. The nurse documents this finding as which of the following?
- A. Akinesia
- B. Dystonia
- C. Pseudoparkinsonism
- D. Akathisia
Correct Answer: D
Rationale: Akathisia is characterized by restlessness and an inability to sit still, common with antipsychotics. Akinesia involves reduced movement, dystonia causes muscle spasms, and pseudoparkinsonism mimics Parkinson?s symptoms like tremor, not restlessness.
A nurse is caring for a psychiatric patient who is receiving an antacid that contains aluminum salts. Which action by the nurse would be most appropriate?
- A. Give the antacid 1 hour before the antipsychotic medication.
- B. Give the antacid at the same time as the antipsychotic medication.
- C. Administer the antacid 1 hour after the antipsychotic medication.
- D. Administer the antacid just before the patient goes to sleep.
Correct Answer: A
Rationale: Aluminum-containing antacids can bind with antipsychotics in the gut, reducing absorption. Administering the antacid 1 hour before the antipsychotic ensures proper absorption of the medication. Giving them together or after may interfere, and bedtime administration is irrelevant to absorption timing.
A patient receiving an antipsychotic agent develops acute extrapyramidal symptoms. Which response by the nurse would be most appropriate?
- A. These symptoms are not real; the medication makes your brain think they are real.
- B. You have developed an allergy to the medication, so we need to change it.
- C. These are the results of the drug that can be treated; your illness is not getting worse.
- D. The sunlight together with the medication has caused these symptoms; just stay indoors.
Correct Answer: C
Rationale: Extrapyramidal symptoms (EPS) are treatable side effects of antipsychotics, not indicative of worsening illness. The nurse?s response should reassure the patient and explain that EPS can be managed. Denying symptoms, suggesting an allergy, or blaming sunlight are incorrect and nontherapeutic.
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