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A nurse is providing teaching to a client diagnosed with schizophrenia and is prescribed haloperidol (Haldol). Which of the following information should the nurse include in the teaching?
- A. This medication will decrease your symptoms of OCD.
- B. This medication may cause excessive salivation.
- C. You can stop taking the medication if the side effects are bothersome.
- D. You may experience dizziness upon standing while taking this medication.
Correct Answer: D
Rationale: The correct answer is D: You may experience dizziness upon standing while taking this medication. This is important information to include because haloperidol can cause orthostatic hypotension, leading to dizziness upon standing. This is a common side effect that the client should be aware of to prevent falls. Option A is incorrect because haloperidol is not used to treat OCD. Option B is incorrect because excessive salivation is not a common side effect of haloperidol. Option C is incorrect because it is crucial not to stop taking antipsychotic medications abruptly without consulting a healthcare provider.
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A nurse is leading a group therapy session for clients who are newly diagnosed with cancer. Which of the following statements should be an appropriate response by the nurse?
- A. Let's discuss what you mean when you say that you cannot ever return to work.
- B. You need to work hard on resolving conflict with those closest to you.
- C. Antidepressants are not your solution, but this therapy group is.
- D. I notice you keep clenching your fists. Why are you doing this?
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Option A demonstrates active listening and encourages further exploration of the client's feelings and perspectives. It shows empathy and promotes open communication. It allows the nurse to understand the client's concerns about returning to work and address them effectively.
Summary:
B: This choice is not appropriate as it focuses on resolving interpersonal conflicts rather than addressing the client's concerns about their diagnosis.
C: This choice dismisses the potential need for medication and minimizes the importance of therapeutic support.
D: This choice addresses a physical behavior without directly addressing the client's emotional concerns about work.
The nurse is teaching a client about cellular hypertrophy. Which statement should be included in the teaching?
- A. It's uncontrolled proliferative cell growth that is cancerous.
- B. It's the enlargement of an organ or tissue from the increase in cell size.
- C. It's the wasting away of tissue or organs.
- D. It's the abnormal growth or development of cells.
Correct Answer: B
Rationale: The correct answer is B because cellular hypertrophy refers to the increase in the size of cells leading to the enlargement of an organ or tissue. This is a normal physiological response to increased demand or stress. Choice A is incorrect as uncontrolled proliferative cell growth leading to cancer is known as neoplasia, not hypertrophy. Choice C is incorrect as wasting away of tissue is termed as atrophy, not hypertrophy. Choice D is incorrect as abnormal cell growth or development is more indicative of dysplasia or metaplasia, not hypertrophy.
A nurse is caring for a client who reports increased anxiety and nervousness,heat intolerance,and unintentional weight loss. Blood testing reveals decreased thyroid-stimulating hormone (TSH),elevated thyroxine (T4) and elevated triiodothyronine (T3) levels. Which of the following vital sign abnormalities does the nurse anticipate?
- A. Hypotension
- B. Tachycardia
- C. Slow respiratory rate
- D. Decreased body temperature
Correct Answer: B
Rationale: The correct answer is B: Tachycardia. In this scenario, the client is showing symptoms of hyperthyroidism, such as increased anxiety, nervousness, heat intolerance, and unintentional weight loss. The decreased TSH and elevated T4/T3 levels indicate an overactive thyroid gland.
Tachycardia is a common symptom of hyperthyroidism due to the increased metabolic rate caused by excess thyroid hormones. The body's response to the increased metabolism is to speed up the heart rate to meet the increased demand for oxygen and nutrients. Therefore, the nurse can anticipate tachycardia in this client.
The other options are incorrect because hypotension is not typically associated with hyperthyroidism; slow respiratory rate is not a common vital sign abnormality seen in hyperthyroidism; decreased body temperature is unlikely as hyperthyroidism usually causes heat intolerance and increased body temperature.
A nurse is assessing a school-age child who recently loaded a virus onto their teacher's computer after receiving a poor grade on a science project. The child's guardian tells the nurse their child often bullies the other kids at school. Which of the following diagnoses should the nurse expect?
- A. Oppositional defiant disorder (ODD)
- B. Attention deficit hyperactivity disorder (ADHD)
- C. Intermittent explosive disorder (IED)
- D. Conduct disorder (CD)
Correct Answer: D
Rationale: Correct Answer: D - Conduct disorder (CD)
Rationale:
1. Conduct disorder involves a pattern of behavior that violates the basic rights of others or societal norms.
2. The child's actions of loading a virus onto the teacher's computer and bullying classmates indicate a disregard for rules and the well-being of others.
3. Conduct disorder commonly presents with aggression, deceitfulness, and violation of rules.
4. These behaviors are more severe than those seen in Oppositional Defiant Disorder (A) and Attention Deficit Hyperactivity Disorder (B).
5. Intermittent Explosive Disorder (C) typically involves impulsive aggression, not premeditated actions like intentionally loading a virus.
6. Conduct disorder is the most appropriate diagnosis considering the child's behavior towards others.
Summary:
- A: Oppositional Defiant Disorder - less severe, lacks the pattern of aggression seen in the child's behavior.
- B: Attention Deficit Hyperactivity Disorder - does not fully capture the intentional harmful behavior
A nurse is talking with a client diagnosed with schizophrenia. Suddenly the client states,I'm frightened. Do you hear that? The voices are telling me to do terrible things. Which of the following responses by the nurse is appropriate?
- A. What are the voices telling you to do?
- B. You need to tell the voices to leave you alone.
- C. You need to understand that there are no voices.
- D. Why do you think you are hearing the voices?
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. **Acknowledge the client's experience**: By asking "What are the voices telling you to do?" the nurse validates the client's experience and shows empathy.
2. **Encourages communication**: This response opens up a dialogue and allows the nurse to gather more information for assessment and understanding.
3. **Avoids dismissing or denying the experience**: Options B and C dismiss or deny the existence of the voices, which can make the client feel unheard or misunderstood.
4. **Promotes therapeutic communication**: Asking about the content of the voices helps the nurse assess the client's level of distress and potential risk.
5. **Supports building trust**: By demonstrating active listening and showing interest in the client's experience, the nurse can build a trusting therapeutic relationship.
Summary:
- Option A is correct as it acknowledges the client's experience and promotes communication.
- Options B and C dismiss or deny the client's experience.
- Option D focuses on the cause rather