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A nurse plans a staff education program for employees of a senior living community. Which topic has priority?
- A. Late-onset schizophrenia
- B. Depression and suicide
- C. Dementia
- D. Delirium
Correct Answer: B
Rationale: Older Americans frequently experience undiagnosed depression and are disproportionately more likely to commit suicide (B). Educating staff about signs and symptoms of high-risk patients and early intervention strategies will decrease morbidity and mortality. The other conditions (A, C, D) have a lower prevalence.
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Which instruction has priority when teaching a patient taking clozapine (Clozaril)?
- A. Avoid unprotected sex.
- B. Report sore throat and fever immediately.
- C. Reduce foods high in polyunsaturated fats.
- D. Use over-the-counter preparations for rashes.
Correct Answer: B
Rationale: The correct answer is B: Report sore throat and fever immediately. This is because clozapine can cause a serious condition called agranulocytosis, which is characterized by a dangerously low white blood cell count. Sore throat and fever can be early signs of this condition, so it is crucial to report them immediately to prevent serious complications.
Avoiding unprotected sex (choice A) is important for overall health but is not directly related to clozapine use. Reducing foods high in polyunsaturated fats (choice C) is not a priority as it does not impact the safety or effectiveness of clozapine. Using over-the-counter preparations for rashes (choice D) is not advised as rashes can be a side effect of clozapine, and professional medical advice should be sought.
A patient has not come out of her room for breakfast. The nurse finds the patient moving restlessly about her room in a disorganized manner. The patient is talking to herself, and her verbal responses to the nurse are nonsensical and suggest disorientation. The nurse notices that the patient's skin is hot and dry, and her pupils are somewhat dilated. All these symptoms are significant departures from the patient's recent presentation. The patient is likely experiencing _____, and the nurse should _____.
- A. Anticholinergic toxicity"¦check vital signs and prepare to use a cooling blanket stat
- B. Relapse of her psychosis"¦administer PRN antipsychotic drugs and notify her physician
- C. Neuroleptic malignant syndrome"¦contact her physician for a transfer to intensive care
- D. Agranulocytosis"¦hold her antipsychotic and draw blood for a complete blood count
Correct Answer: A
Rationale: The correct answer is A: Anticholinergic toxicity. The patient's symptoms of restlessness, disorganized behavior, nonsensical speech, disorientation, hot and dry skin, dilated pupils, and significant departure from recent presentation are classic signs of anticholinergic toxicity. Anticholinergic medications can lead to central nervous system and peripheral anticholinergic effects, causing confusion, delirium, hyperthermia, and dilated pupils. Checking vital signs and preparing to use a cooling blanket are appropriate initial interventions to address the symptoms.
Choices B, C, and D are incorrect because they do not align with the patient's symptoms and presentation. Choice B (Relapse of her psychosis) does not fully explain the physical symptoms such as hot and dry skin, dilated pupils, and disorientation. Choice C (Neuroleptic malignant syndrome) typically presents with muscle rigidity, hyperthermia, autonomic instability, and altered mental status, which are not completely consistent
A school-aged patient with attention-deficit hyperactivity disorder (ADHD) is displaying disruptive behaviors at home. The psychiatric-mental health nurse modifies the treatment plan for the social domain, by advising the patient's parents to:
- A. establish eye contact before giving directions
- B. initiate a point system, to reward the patient for appropriate behavior
- C. instruct the patient to work on one homework assignment at a time
- D. maintain a predictable environment in the home
Correct Answer: B
Rationale: A point system reinforces positive behavior, directly addressing social disruptiveness in ADHD.
An individual brought by ambulance to the emergency room is accompanied by a roommate. The patient fights against the restraints and shouts incoherently. The roommate reports that the patient was weak and confused on awakening this morning and about 3 hours ago began "rambling and talking crazy."Â A nurse notes that the patient's skin is flushed and dry. The priority nursing action is to:
- A. take the patient's vital signs.
- B. start intravenous fluids.
- C. administer a sedative.
- D. perform a mental status examination.
Correct Answer: A
Rationale: The correct answer is A: take the patient's vital signs. This is the priority action because the patient is exhibiting signs of potential medical emergency, such as altered mental status, flushed and dry skin, and confusion. Vital signs can provide crucial information about the patient's condition and help determine the urgency of the situation. Starting intravenous fluids (B) may be necessary but should be based on the assessment of vital signs first. Administering a sedative (C) is not appropriate without knowing the underlying cause of the symptoms. Performing a mental status examination (D) is important but not the priority in this situation where the patient's physical condition needs immediate attention.
The elderly spouse of a female Alzheimer's client states that his wife seems to wander aimlessly from room to room looking for things in incorrect places, such as kitchen utensils in the bedroom and laundry detergent in the kitchen. He asks the nurse for suggestions of what he can do to help her. What is the nurse's best response?
- A. Keep rooms well lit.'
- B. Keep the home environment simple and user-friendly for her.'
- C. Have clocks and calendars with large letters in several rooms of the house.'
- D. Place large signs on doors or entryways that identify the room.'
Correct Answer: D
Rationale: The correct answer is D: Place large signs on doors or entryways that identify the room. This is the best response because it directly addresses the issue of the client's confusion and disorientation by providing clear visual cues to help her navigate the home environment effectively. By labeling the rooms with large signs, the client can easily recognize where she is and find what she needs. This strategy helps reduce her anxiety and frustration, promoting a sense of independence and safety.
Choices A, B, and C are incorrect because they do not specifically target the client's cognitive challenges related to Alzheimer's disease. Keeping rooms well lit, having a simple environment, and using clocks with large letters are helpful suggestions but do not address the primary issue of the client's spatial disorientation and confusion. Placing large signs on doors directly addresses the client's specific needs and is the most effective strategy in this situation.