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A client with schizophrenia is prescribed risperidone. Which of the following should the nurse monitor for as an adverse effect of this medication?
- A. Increased blood pressure
- B. Weight gain
- C. Excessive salivation
- D. Bradycardia
Correct Answer: B
Rationale: The correct answer is B: Weight gain. Risperidone, an atypical antipsychotic, is known to cause metabolic side effects such as weight gain. This occurs due to its effects on increasing appetite and altering metabolism. Monitoring weight regularly is crucial to detect and manage this adverse effect to prevent complications like diabetes and cardiovascular issues. Increased blood pressure (A) is not a common adverse effect of risperidone. Excessive salivation (C) is more commonly associated with medications like clozapine. Bradycardia (D) is not a typical side effect of risperidone.
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A home health nurse is planning care for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?
- A. Replace the carpet with hardwood floors.
- B. Encourage physical activity prior to bedtime.
- C. Wear clothing with zippers instead of buttons.
- D. Place locks at the tops of exterior doors.
Correct Answer: D
Rationale: The correct answer is D: Place locks at the tops of exterior doors. This is important for the safety of a client with Alzheimer's disease who may wander. Placing locks at the tops of doors can prevent the client from easily opening them and wandering off, which is a common behavior in Alzheimer's patients.
A: Replacing carpet with hardwood floors may not directly address the safety concern of wandering.
B: Encouraging physical activity prior to bedtime may help with sleep but does not address the safety issue of wandering.
C: Wearing clothing with zippers instead of buttons may be easier for the client to manage, but it does not address the safety concern of wandering.
Summary: The key consideration in caring for a client with Alzheimer's disease is ensuring their safety, particularly in preventing wandering, which is why placing locks at the tops of exterior doors is the most appropriate action.
A nurse is planning care for a client who has borderline personality disorder and engages in self-mutilation. Which intervention should the nurse include?
- A. Restrict the client's access to personal belongings.
- B. Encourage the client to express feelings of anger.
- C. Place the client in seclusion when self-injurious behavior occurs.
- D. Tell the client to stop the self-mutilation behavior.
Correct Answer: B
Rationale: The correct answer is B: Encourage the client to express feelings of anger. This intervention helps the client explore and process underlying emotions contributing to self-mutilation. It promotes emotional awareness and healthy coping mechanisms. Restricting personal belongings (A) may escalate feelings of frustration. Seclusion (C) can be traumatic and worsen abandonment fears. Telling the client to stop (D) oversimplifies a complex issue and may lead to resistance.
A nurse is planning care for a client who has borderline personality disorder and engages in self-mutilation. Which intervention should the nurse include?
- A. Restrict the client's access to personal belongings.
- B. Encourage the client to express feelings of anger.
- C. Place the client in seclusion when self-injurious behavior occurs.
- D. Tell the client to stop the self-mutilation behavior.
Correct Answer: B
Rationale: The correct answer is B: Encourage the client to express feelings of anger. For clients with borderline personality disorder, self-mutilation often stems from difficulty in managing intense emotions. Encouraging the client to express feelings of anger can help them process and cope with their emotions in a healthier way, reducing the need for self-harm. Restricting access to personal belongings (A) may increase feelings of frustration and lead to more self-mutilation. Placing the client in seclusion (C) can worsen feelings of isolation and may not address the underlying emotional issues. Simply telling the client to stop self-mutilation (D) is not effective as it overlooks the complex emotional reasons behind the behavior.
A nurse is working with a client who has an anxiety disorder and is in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase?
- A. We should discuss resources to implement in your daily life.
- B. Let me show you simple relaxation exercises to manage stress.
- C. We should establish our roles in the initial session.
- D. Let's talk about how you can change your response to stress.
Correct Answer: C
Rationale: Correct Answer: C
Rationale: During the orientation phase of the therapeutic relationship, establishing roles is crucial for setting boundaries and clarifying expectations. This helps build trust and create a safe environment for the client to open up. Discussing resources (A) and relaxation exercises (B) would be more appropriate in later phases once the therapeutic relationship is established. Talking about changing responses to stress (D) may be premature at this stage.
A nurse is assessing a client who has histrionic personality disorder. Which of the following manifestations should the nurse expect?
- A. Suspicious of others
- B. Callousness
- C. Self-centered behavior
- D. Violates others' rights
Correct Answer: C
Rationale: The correct answer is C: Self-centered behavior. Histrionic personality disorder is characterized by attention-seeking behavior, excessive emotions, and a need for approval. Individuals with this disorder often exhibit self-centered behavior to gain attention and validation from others. Choice A is incorrect as suspicion of others is more indicative of paranoid personality disorder. Choice B, callousness, is not a typical feature of histrionic personality disorder, but rather more aligned with antisocial personality disorder. Choice D, violating others' rights, is more characteristic of individuals with antisocial personality disorder as well.