Nokea
A patient is hospitalized for severe depression. Of the medications listed below, the nurse can expect to provide the patient with teaching about:
- A. Chlordiazepoxide (Librium).
- B. Clozapine (Clozaril).
- C. Sertraline (Zoloft).
- D. Tacrine (Cognex).
Correct Answer: C
Rationale: Rationale:
1. Severe depression is typically treated with antidepressants like Sertraline (Zoloft).
2. Sertraline is a selective serotonin reuptake inhibitor (SSRI) commonly used to treat depression.
3. The nurse should provide teaching on how to take the medication, potential side effects, and monitoring for effectiveness.
4. Other choices (A, B, D) are not typically used as first-line treatment for severe depression and may not be appropriate for this patient.
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At what age do the synaptic connections in human brain peak?
- A. At birth
- B. End of 3 years
- C. 5 years
- D. 8 years
Correct Answer: B
Rationale: Synaptic connections peak around the end of 3 years (B), a period of rapid synaptogenesis and neural plasticity, followed by pruning. At birth (A), development begins, while 5 (C) and 8 years (D) see continued growth but past the peak, per neurodevelopmental research.
An 11-year-old child stays home from school to care for his siblings while his mother works, is demeaned by his father, and has negative self-perceptions. Which indicator would suggest that nursing interventions are succeeding?
- A. The child attends school regularly.
- B. The child is observed playing calmly.
- C. The father rarely speaks during nurse visits.
- D. The mother corrects negative comments by the child.
Correct Answer: A
Rationale: The correct answer is A because regular school attendance indicates the child's improved well-being and ability to prioritize education over caregiving responsibilities.
B: Playing calmly does not necessarily indicate overall improvement in the child's situation.
C: The father's silence during nurse visits does not directly reflect the child's well-being or progress.
D: The mother correcting negative comments by the child is positive but does not directly address the child's caregiving responsibilities or self-perceptions.
A patient receiving risperidone (Risperdal) reports severe muscle stiffness midmorning. During lunch he has difficulty swallowing food and speaking, and when vital signs are taken 30 minutes later, he is noted to be stuporous and diaphoretic, with a temperature of 38.8° C, pulse of 110 beats/min, and blood pressure of 150/90 mm Hg. The nurse should suspect ______ and should ______.
- A. neuroleptic malignant syndrome"¦place him in a cooling blanket and transfer to ICU
- B. anticholinergic toxicity"¦check vital signs and prepare to use a cooling blanket stat
- C. relapse of his psychosis"¦administer PRN antipsychotic drugs and notify his physician
- D. agranulocytosis"¦hold his antipsychotic and draw blood for a complete blood count
Correct Answer: A
Rationale: The correct answer is A: neuroleptic malignant syndrome (NMS). The patient's symptoms align with NMS, a rare but serious side effect of antipsychotic medications like risperidone. The severe muscle stiffness, difficulty swallowing, altered mental status, diaphoresis, and elevated temperature, pulse, and blood pressure are all indicative of NMS. The nurse should suspect NMS and take immediate action by placing the patient in a cooling blanket to lower the temperature and transfer him to the ICU for close monitoring and further management.
Choice B is incorrect because anticholinergic toxicity typically presents with different symptoms such as dry mouth, dilated pupils, and confusion. Choice C is incorrect as there are no signs of a psychotic relapse, and administering more antipsychotic medication could worsen the NMS. Choice D is incorrect as agranulocytosis presents with symptoms like fever and sore throat, not the combination of symptoms seen in this case.
The client tells the nurse, 'I thought my psychiatrist was the best doctor in the world. I thought he understood me completely. Now, I hate him! He doesn't understand me at all. He's just dumping me to go on a 2-week vacation.' The nurse assesses the client's description of feelings about the physician as evidence of the use of:
- A. Splitting
- B. Projective identification
- C. Isolation of affect
- D. Dissociation
Correct Answer: A
Rationale: The correct answer is A: Splitting. Splitting is a defense mechanism where a person sees things in extremes of either all good or all bad. In this scenario, the client initially idealizes the psychiatrist as the best doctor, then suddenly devalues and hates him for taking a vacation, indicating a shift from all good to all bad. This extreme change in perception is characteristic of splitting.
B: Projective identification involves projecting one's own feelings onto another person and then identifying with those projected feelings. This choice does not fit the scenario as the client is not projecting their feelings onto the psychiatrist.
C: Isolation of affect refers to the separation of feelings from ideas and events. The client's strong emotions towards the psychiatrist do not demonstrate a lack of emotional expression or detachment from feelings.
D: Dissociation is a defense mechanism where thoughts, feelings, and experiences are separated from conscious awareness. The client's reaction does not suggest a disconnection from reality or consciousness.
A newly admitted patient diagnosed with paranoid schizophrenia is hypervigilant and constantly scans the environment. He states that he saw two doctors talking in the hall and knows they were plotting to kill him. When charting, how should the nurse identify this behavior?
- A. Idea of reference
- B. Delusion of infidelity
- C. Auditory hallucination
- D. Echolalia
Correct Answer: A
Rationale: The correct identification for the behavior described is "A: Idea of reference." This term refers to the belief that neutral events are directed at oneself. In this case, the patient's belief that the doctors were plotting to kill him is an example of a false idea of reference. Delusion of infidelity (choice B) involves false beliefs about a partner's unfaithfulness, not relevant here. Auditory hallucination (choice C) pertains to false perceptions of hearing sounds, not applicable. Echolalia (choice D) is the repetition of words spoken by others, not seen in this scenario. Identifying the behavior as an idea of reference helps the nurse understand the patient's distorted perception of reality.