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A nurse is teaching a client who has schizophrenia about the adverse effects of clozapine. Which of the following side effects should the nurse include in the teaching?
- A. Increased salivation
- B. Tardive dyskinesia
- C. Hypertension
- D. Photosensitivity
Correct Answer: B
Rationale: The correct answer is B: Tardive dyskinesia. Clozapine can lead to this side effect, which is characterized by involuntary movements of the face and body. This is important to include in teaching as it can be a serious and potentially irreversible effect of the medication. Increased salivation (choice A) is not a common side effect of clozapine. Hypertension (choice C) is not typically associated with clozapine use. Photosensitivity (choice D) is not a common side effect of clozapine. Overall, choice B is the correct answer as it aligns with the known side effects of clozapine in individuals with schizophrenia.
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A nurse is caring for a client who exhibits excessive compliance, passivity, and self-denial. The nurse should recognize that these findings are associated with which of the following personality disorders?
- A. Dependent
- B. Paranoid
- C. Borderline
- D. Histrionic
Correct Answer: C
Rationale: The correct answer is C: Borderline. Excessive compliance, passivity, and self-denial are characteristic traits of individuals with Borderline Personality Disorder. They often struggle with identity, exhibit intense emotions, and have unstable relationships. Choice A, Dependent Personality Disorder, is characterized by a pervasive psychological dependence on others. Choice B, Paranoid Personality Disorder, involves distrust and suspiciousness. Choice D, Histrionic Personality Disorder, is characterized by attention-seeking behavior and emotional overreaction. Choices E, F, and G are irrelevant. In this scenario, the client's behaviors align most closely with the features of Borderline Personality Disorder.
A nurse is caring for a client who has major depressive disorder and is prescribed sertraline. Which of the following instructions should the nurse provide?
- A. Take the medication at bedtime
- B. Expect results within 1 to 2 days
- C. Avoid consuming grapefruit juice
- D. Stop taking the medication once symptoms improve
Correct Answer: C
Rationale: The correct answer is C: Avoid consuming grapefruit juice. Grapefruit juice can interact with sertraline, leading to increased levels of the medication in the bloodstream, potentially causing side effects or toxicity. It is essential for the nurse to instruct the client to avoid grapefruit juice to ensure the safe and effective use of sertraline. Taking the medication at bedtime (choice A) is not specifically necessary for sertraline. Expecting results within 1 to 2 days (choice B) is incorrect as antidepressants like sertraline typically take weeks to show full effects. Stopping the medication once symptoms improve (choice D) can be dangerous as abruptly discontinuing an antidepressant can lead to withdrawal symptoms or a relapse of depression.
A nurse is reviewing laboratory findings for a client who is taking valproic acid. Which of the following results should the nurse report to the provider?
- A. Platelets 250,000/mm³
- B. AST 45 units/L
- C. WBC 9,000/mm³
- D. ALT 65 units/L
Correct Answer: D
Rationale: The correct answer is D: ALT 65 units/L. Elevated ALT levels indicate potential liver damage, a known side effect of valproic acid. The nurse should report this to the provider for further evaluation. Platelets, AST, and WBC levels are within normal ranges, so they do not require immediate reporting. In summary, the correct answer is focused on a potential serious side effect related to the medication, while the other choices are not directly linked to valproic acid or indicate normal laboratory values.
A nurse in a community clinic is planning an educational session for a group of clients. Which of the following strategies should the nurse use when teaching about stress management?
- A. Provide lengthy lectures on stress
- B. Encourage discussion and practice of coping skills
- C. Discourage clients from expressing emotions
- D. Teach all clients the same stress-reduction technique
Correct Answer: B
Rationale: The correct answer is B: Encourage discussion and practice of coping skills. This strategy is effective because it actively engages clients in learning and applying coping mechanisms, promoting better retention and skill development. By encouraging discussion, clients can share experiences and support each other, enhancing their understanding and motivation. Practicing coping skills helps clients to internalize and apply them in real-life situations.
Incorrect choices:
A: Providing lengthy lectures is less effective as it can be overwhelming and may not actively involve clients in learning.
C: Discouraging clients from expressing emotions hinders the therapeutic process and can lead to bottling up emotions, increasing stress.
D: Teaching all clients the same technique may not address individual needs and preferences, limiting the effectiveness of stress management strategies.
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.